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C0FHUGHT DEPOSIE 



THE OPERATING ROOM 

A PRIMER FOR PUPIL NURSES 



BY 

AMY ARMOUR SMITH, R. N. 

FORMERLY SUPERINTENDENT OF NEW ROCHELLE HOSPITAL, NEW 

YORK ; SUPERINTENDENT OF NURSES AT THE S. R. SMITH INFIRMARY, 

STATEN ISLAND, AND AT THE WOMAN'S HOSPITAL OF THE STATE 

OF NEW YORK 




PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1916 






/&# 



Copyright, 1916, by W. B. Saunders Company 



OCT 214916 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



©CLA445263 



TO 
MINE OWN PEOPLE 



FOREWORD 



This little book has been slowly and anxiously pieced 
together not by one continuous task, but by culling an 
idea here, a formula there, a test somewhere else, from 
the conversations of numerous good friends in the medical 
and nursing professions, and from happy memories of 
days in training under the kindly, thorough instruction of 
Miss A. M. Rykert and Miss J. MacCallum (now Mrs. 
Schenck, of Detroit), for the opportunity to be under 
whom those who were so fortunate have been increasingly 
proud and grateful as time goes by/ Yet, withal, this 
book will seem rather crude in comparison with the finished 
work of experienced authors. Generously excuse its 
faults on the ground that it is only a pioneer, from a nurse 
to nurses, and not from a physician to nurses! These data 
have been garnered from journals on nursing, from physi- 
cians' libraries, and from the practical experiences of 
friends. If its humble appearance proves to be an in- 
spiration to others more skilled, to take up the labor and 
go farther, it will have accomplished much. If, again, 
any nurse chances to learn that she too can constantly 
acquire information that may be at any time, no matter 
how remote, tremendously useful to her, it will not have 
been written in vain. 

My sincere thanks are due to Dr. T. Mitchell Prudden 
and Dr. W. M. Brickner for permission to quote from 
their valuable works, to Dr. C. A. Smith and Dr. C. H. 
Fulton for their constant personal assistance, to Dr. E. M. 
Smith and Dr. A. Beck for contributions on their special 
lines of work, to Mr. F. H. Kollman for useful pharma- 
ceutic data, and to the firms Kny-Scheerer Corporation, 

9 



10 FOREWORD 

Foregger Co., Inc., Lentz & Sons, for the loan of 
numerous electrotypes, and to J. F. Newman, manufac- 
turing jeweller, for the design on the title-page. 

Most especially, however, this work has been forwarded 
and is largely due to the encouragement and careful 
revision given by Miss B. I. Brazeau, R. N., and Miss I. 
M. Hall, R. N., two operating-room nurses, whose abso- 
lute conscientiousness, skill, and willing spirit, enhanced 
by many tenderer graces that make the perfect woman, 
deserve a far higher tribute than can here be given. 

" The Trained Nurse and Hospital Review " kindly 
gave permission to use the original articles which were 
expanded for some of these chapters. 

Amy Armour Smith. 

New Rochelle, N. Y. 
September, 1916. 



CONTENTS 



CHAPTER I page 

Operating-room Pupils 17 

Rotation of Service, 17— The First Day, 18— The Little 
Hospital, 18— The Surgeon's Duty to the New Pupil, 20— 
Good vs. Bad Judgment, 21 — The Telephone, 22 — Some 
Ways of Arranging Work, 22 — Importance of Dusting, 23— 
Honesty in Running the Sterilizers, 24 — Some Difficulties 
which the Supervisor Has to Solve, 24 — Sequence of In- 
struction, 25 — Routine Cleaning, 26 — Utensils and Linen, 
27 — Classes in Anatomy Daily, 29 — Impartiality, 29 — 
Relation Between the Operating Room and the Ward, 30 — 
Best Time to Give a Pupil this Service, 31 — Deportment, 31 
—Eight-hour Day, 32— Scholarships, 32— Visitors, 33— 
Presence Not Demanded in Genito-urinary Work, 33 — 
Moving Pictures as Educational Feature, 34. 

CHAPTER II 

The Junior Nurse 36 

Her Numerous Duties, 36 — Sharpening the Instincts 
to Judge Time, Distance, etc., 39 — Visitors, 42 — How to 
Get Ready for a Second Case, 43 — Messages To or For the 
Doctor, 45 — Engineer's Instructions, 46 — Perspiration, 48 
— Orders to the Wards, 48 — Special Beds, 48. 

CHAPTER III 

The Anesthetic Nurse 50 

Positions for Operation, 50 — Setting Up the Anesthetic 
Room, 53 — Greeley Units for the Stimulation Tray, 54 — 
Duties to the Patient, 56 — Duties to the Anesthetist, 57 — 
Problem of Nurses' Giving Anesthetics, 58 — How to Fol- 
low One Case by Another, 59 — Oxygen, 59 — After the 
Operation, 61 — Special Anesthetics, 63 — Spinal Anesthesia, 
63 — Rectal Anesthesia, 63 — The Pulmotor, 64. 

CHAPTER IV 

The Scrubbed Nurse 66 

Procedure During a Case, 66 — Sutures, 67 — Needles, 67 
— Ligatures, 68 — Scissors, 68 — Forceps, 68 — Instruments 
in General, 68 — Height of Table, 69 — Instruction in Con- 
ducting an Operating Room, 69 — General Hints, 71. 

11 



12 CONTENTS 

CHAPTER V page 

The Head Nurse 77 

Preparedness, 77 — Discipline, 78 — Teaching Method, 79 

— Nursing, 80 — Common Faults in Operating Rooms, 81 — 

Legal Phases in Her Duties, 81 — Routine Work, 82 — 

t Ethical Relations with the Rest of the House, 87 — To the 

' Community, 88 — Economy of the Right Kind, 89. 

CHAPTER VI 

The Main Operating Room . 90 

Position Relative to the Main Building, 90 — Lighting, 90 
— Ventilation, 90 — Temperature, 92 — Clothing Required 
to Work Comfortably, 92 — Corners, 93 — Fumigation, 93 — 
Instrument Cases, 94 — Dark Room, 95 — Plumbing, 96 — 
The Table, 97 — Terms Used in Electric Appliances, 97 — 
Silent Clock, 98— Special Table Pads, 99— Tonsil Table, 99 
— Cautery, 99 — A Cleanly Way to Evacuate a Cyst, 99 — 
Radium Outfit, 101— Doors, 101— Waste Receptacles, 101 
— Other Rooms of the Suite, 101 — Elevators, 102 — Fire 
DriU, 102. 

CHAPTER VII 

The Sterilizing Room 104 

Open-air Shaft to Reduce Humiditv, 104 — Cold Coil on 
Both Water Tanks, 104— Filters, 105— Fixtures, 105— 
Height Not Desirable for Tanks, etc., 105 — Engineer's In- 
structions, 106 — Perfected Autoclave, 106 — Packing Drums, 
106— Duty of Night Nurses, 107— Tests for Complete Ster- 
ilization, 107 — Distillation of Water, 107 — Making Saline, 
108— Clock, 108— Other Sterilizers, Gloves, Utensils, In- 
struments, etc., 108 — Special Precautions with Apparatus, 
109 — Infections Due to this Department, 109 — Safety 
Devices, 109— Blanket Warmer, 110— Electricity, 110— 
Flooring, 110. 

CHAPTER VIII 

The Workrooms Ill 

Size, Ventilation, 111 — Cupboards, 111 — Desk, Counter, 
Seats, and Foot-rests, 111 — Rules for Work, 112 — Hopper 
Room, 113. 

CHAPTER IX 

Asepsis ; . 114 

Definition, 114 — Methods of Carrying Out Asepsis, 114 
— Damp Dressings, 115 — Mechanical Cleanliness, 116 — 
Covers, 116— Caps, Masks, Glasses, 116 — How to Stand, 
117 — Tests by Cultures, 118 — Tracing the Aseptic Chain, 
119 — Some Errors in Technic, 122 — How to Handle Goods 
from a Jar, 124 — Dusting, 127 — Orderlies, 127 — Where the 
Anesthetist May Work, 127 — Contaminated Instruments, 
128 — Breaks in Asepsis, 128 — How to Reduce the Activity 



CONTENTS 13 

PAGE 

of Bacteria Liberated by Any Wound, 128— Table, 129— 
Floors, 129— Walls, 129— Shoes, 130— Health of Attend- 
ants, 130 — Emergency Cases, 131 — Contagious Cases, 131 
— Clean Cases, 132 — Some Problems Confronting the 
Supervisor, 133— Nurses Who Are 111, 133. 

CHAPTER X 

Formula and Directions 136 

Thiersch's Solution, 136 — Carrel-Dakin Antiseptic, 136 — 
Iodoform Packing, 136 — Catgut, 137 — Kangaroo Tendon, 
138— Horsehair, 138— Silkworm-gut, 138— Silk, 138— 
Bone-wax, 138 — Aluminum Acetate Solution, 138 — Boric 
Acid, 139 — -Normal Saline, 139 — Solutions of Bichlorid of 
Mercury, 140 — Formaldehyd, 141 — Nitrate of Silver, 141 — 
Narcotics and Local Anesthetics, 142 — One Per Cent. 
Solutions, 142 — Rubber Tissue, 143 — Care of Rubber 
Gloves, 144 — Rubber Tubing, 146 — Catheters, Filiforms, 
and Bougies, 146 — Preservation of Specimens, 148 — Hard 
Black Rubber Goods, 148— Silver Leaf, 149— Care of In- 
struments, 149 — Care of Soft-rubber Articles, 150 — How 
to Sterilize Adhesive, 150 — Eye Knives, 151 — Glass 
Syringes, 151 — Tracheotomy Tubes, 151 — Hospital Cold 
Cream, 152 — Hospital Hand Lotion. 152 — To Sterilize 
Vaselin, 152. 

CHAPTER XI 

The Metric System. Some Brief Notes 153 

Length, 153 — Volume, 154 — Weight, 155. 

CHAPTER XII 

Special Dressings 157 

Mastoid Tips, 157 — Mastoid Dressing, 157 — Gant Pad, 
158 — Tampon Canula, 158 — Canule a Chemise, 158 — 
. Leg Rolls, 159— Tampons, 159— Small Sponges, 159— Cloth 
Retractors, 160 — Bandaging, 160 — Making Packing, 160 — 
Eye Pads, 160— Aristol Pledgets, 160— Applicators, 161— 
Tape Stickers, 161. 

CHAPTER XIII 

Terms Used in Surgical Diagnosis 163 

A List of Terms Describing the Pathologic Conditions 
that Require Operation and Their Definitions, 165. 

CHAPTER XIV 

Lists of Instruments for Certain Operations, with Acces- 
sory Articles, and Details of Actual Operating- 

toom Nursing Care 185 

Head, 185 — Mastoid, 186 — Cataract, 188 — Submucous 
Resection of the Nasal Septum, 188 — Frontal Sinus 
(Radical), 189 — Radical Operation on the Ear, 190 — Jugu- 



14 CONTENTS 

PAGB 

lar Operation, 190 — Strabismus Operation, 190 — Enuclea- 
tion of the Eye, 191— Adenoids, 191— Tonsils, 191— 
Pharyngeal Abscess, 192 — Tracheotomy, 192 — Brain Ab- 
scess, 192 — Skin-grafting, 193 — Breast Amputation, 193 — 
Resection of Rib for Empyema, 194 — Appendectomy, 196 . 
— Cholecystotomy, etc., 198 — Gastrostomy, etc., 200 — 
Hysterectomy, 200 — Cesarean Section, 202 — Herniotomy, 
203— Nephrectomy, etc., 203— Curettage, 205— Trachelor- 
rhaphy, 206 — Perineorrhaphy, 206 — Hemorrhoidectomy 
(Ligation Method), 206 — Operation on Fistula in Ano, 207 
— Hemorrhoidectomy (Clamp and Cautery Method), 207. 

CHAPTER XV 

Nomenclature 209 

A List of the Terms Used in Naming What is Done in 
the Operating Room, with Definitions, 211. 

CHAPTER XVI 

Linen of the Operating Room 217 

How to Estimate the Amount Needed, 217 — Patterns, 
217— White Linen, 218— Method of Laundering, 218— Open 
Net Bags, 219— Men's T-Binders, 219— Suspensories, 219— 
Scultetus Binders, 220 — Laparotomy Gowns and Stockings, 
220— Breast Binder, 221— Caps, 221— Masks, 222— Vaginal 
Sheets, 223— Covers for Tubes of Packing, 225— Special 
Gown Covers, 225 — Special Glove Covers, 225 — Folding 
Linen, 225— Folding Gowns, 226— Blankets, 228— Stains, 
228 — Linen for Isolated Cases, 229 — Measures for Suits and 
Gowns to Fit All Figures, 229. 

CHAPTER XVII 

Buying for the Operating Room 230 

Things N.)t to Buy, 230— A Buyer's Duty, 230— Ameri- 
can Hospital Bureau of Standards and Supplies, 231 — Trade 
Names, 232— Buying a Good Quality of Stimulants, 232— 
Process of Obtaining Alcohol and Safeguarding It, 232 — 
How to Act When an Important Article is Needed in an 
Unforseen Contingency, 233 — Expense, 233. 

CHAPTER XVIII 

Minor Work in the Operating Room or Based on Its 

Technic 234 

Intravenous Infusion, 234 — Hypodermoclysis, 242 — In- 
jection of Blood-serum, 243 — Transfusion, 244 — Phlebot- 
omy, Venesection, Blood-letting, 246 — Lumbar Puncture, 
247— Injection of Antimeningitic Serum, 247 — Spinal Anes- 
thesia, 248 — Artificial Respiration, 248. 



CONTENTS 15 

CHAPTER XIX 

PAGE 

Preparations by the Nurse in Orthopedic Surgery 250 

Definition of Terms of Pathologic Conditions, 250 — 
Description of Apparatus to Be Made in Any Operating 
Room, 252 — Bradford Frame, 252 — Buck's Extension for 
Fracture, 253 — Articles for the Lorenz Operation, 256 — 
Ordinary Plaster Cast, 257 — Putting on a Cast, 258 — 
Special Instructions, 260 — Orthopedic Tables, 262 — Strap- 
ping for Flat-foot, 262 — Limitations of General Hospitals, 
262 — Explanation of Terms Relating to Unusual or Special 
Apparatus, 263. 

CHAPTER XX 

Improvised Operating Room in a Humble Home 266 

Some Hints, 266 — First Preparations, 266 — Linen, 266 : — 
How to Sterilize, 266— Saline, 266— Operating Table, 267 
— Trendelenburg Position, 267 — Improvised Kelly Pad, 
269— Stretcher, 270— Gown, 272— Cap and Mask for the 
Nurse, 272— Cleaning the Room, 272. 

CHAPTER XXI 

A Plea to the Superintendent in Behalf of the Oper- 
ating Room 274 

Its Value to the Superintendent in His Administration, 
274— Needs, 274— Sale of Sterile Goods, 274— Library, 275 
— Buying Quickly, 275 — Observation Trips of Supervisor 
and Pupils to Other Institutions, 275 — Notifying the 
Operating Room of Every Case Coming In, 276 — Reinforce- 
ment in a Rush, 276 — Large Reserve Stock, 276 — The 
Laundry, 277 — The Superintendent's Attitude to the 
Nurses During a Case, 277 — Supporting the Supervisor by 
Providing Good Servants, 278. 

CHAPTER XXII 

The Choice and Appointment of an Operating Room Su- 
pervisor 280 

Importance, 280— Relation to Other Officials, 281— De- 
sirable Qualities, 280 — Testimonials, Degrees, and Demon- 
strating Abilitv, 282 — Method of Conducting Interview, 
282— Ratification by Board of Governors, 283— The 
Supervisor's Side, 284 — Registries as Bureaus of Informa- 
tion, 284 — "Pull," 285 — Duties of the American Hospital 
Association, 286. 

Index 289 



OPERATING ROOM 



CHAPTER I 



OPERATING-ROOM PUPILS 

"A task! — To be honest, to be kind; ... to renounce when that 
shall be necessary and not be embittered; to keep a few friends, 
and these without capitulation; above all, on the same grim con- 
dition, to keep friends with himself; here is a task for all that man 
has of fortitude and delicacy." — Robert Louis Stevenson. 

Rotation of Service. — The superintendent or directress 
of nurses must keep the operating-room supervisor thor- 
oughly posted about the pupils' rotation of service, so 
that a new pupil's arrival in that department does not 
interfere with the smoothness of its workings. Then, 
too, illness and vacations being taken into consideration, 
there must always be available one nurse at least in small 
hospitals, more in the larger, who is free to go back to 
that service when needed. There is a tension and im- 
portance about this "core of the house" that enforces a 
sort of militarism, or establishment of a standing army 
of nurses who "have had operating room." There is a 
very pleasurable excitement in the arrival of one nurse 
and the departure of another, a large amount of specu- 
lation about where the latter will go, and how the former 
will fit in, that varies the monotony of the daily round '. 
It has often been demonstrated that out of very un- 
promising material a good operating-room nurse can be 
made, because of her sudden flaming-up of enthusiasm 
for a new kind of work in this tense atmosphere. We 
call it the "core" of the house because it contains all the 

2 17 



18 OPERATING ROOM 

seeds of the future success of the institutions which under- 
take work that cannot be with equal facility and success 
conducted at home, and which are to be supervised by 
some of these same pupils in the future. 

The First Day. — By a careful planning, calculating 
on the help in any emergency of the pupils who have 
finished the service, so as to be perfectly free to teach, 
in a period void of excitement or demands on her atten- 
tion, the supervisor greets her novice in the early morn- 
ing of the first day and begins at once to devote a cer- 
tain number of hours to instructing her in the primary 
duties she will have to perform. It is impossible to de- 
vise arrangements to suit the operating-room personnel 
of all hospitals that undertake surgery, whether general, 
special, private, charitable only, or emergency, and be- 
sides, in a very large city where all these kinds exist side 
by side, conditions are so dominant as to force their work 
into certain grooves. It is rather toward the small hos- 
pitals in the suburban counties that these chapters are 
directed, since they toss hither and thither on the reefs 
of crystallized whims of a few men who by their early 
pugnacity, doubtful politics, or genuine philanthropy 
became the pillars of the staff and brought to its beds 
patients of such substantial means that the Board of 
Directors brings a pressure to bear on all resident officials 
to humor their notions somewhat. A generous, open- 
handed community, an upright body of governors, and 
an ethical Medical Board are the things to be desired for 
the hospital's backing, and it is in the hope that these 
are the goal of each man's ambition that the suggestions 
herein contained have been evolved. 

The Little Hospital. — Many little operating rooms 
have been successfully conducted by one graduate nurse 
who at times performed other duties in the hospital as 
w T ell, simply calling one pupil from the wards during the 
period when the patient is under the anesthetic. Some 
have one steady pupil and one on call, others two steady 
pupils, and so on, up to the large institutions which con- 



OPERATING-ROOM PUPILS 19 

duct several operating rooms en suite at once, with the 
large staff of pupils working interchangeably to their 
mutual advantage. Let not the little hospital force be 
discouraged, however, because its gains are "writ large" 
in accuracy, thoroughness, and personal interest in surgeon 
and patient, besides a breadth sometimes that is derived 
from acquaintance with the methods of maybe as many 
as twenty-five of the picked surgeons from a near-by 
metropolis, who are pleased to come out to operate on 
the wealthy residents and find faithful, unerring service. 

The little operating room was the first to subscribe to 
the wish now almost universally voiced, to standardize 
operating-room technic. The operating-room supervisor, 
as well as all officials above her, should be a member of 
the American Hospital Association, and become identified 
with the sessions of the surgical department. The Board 
of Directors should pay her or their expenses to these 
conferences, and demand a good report, and progress in 
the service of the hospital later. It is also incumbent 
upon us to promote more frequent conferences among 
these supervisors within our own counties. They are 
very important people. The occupations of the in- 
habitants, inclement climate, facilities for transportation 
all determine largely not only the hours at which opera- 
tions are held, but the nature of the cases to be done. 
When they meet they should not brag about how they 
do things, but should ventilate all their difficulties and 
say, "How do you do this thing? How do you manage 
when that event happens? What percentage of skin in- 
fections do you get?" This requires the hearty coopera- 
tion of the senior officers in the hospital to arrange for 
substitutes and traveling expenses. 

The large institutions of the nearby cities should be 
visited to see modern equipment, new methods, and often 
to derive, maybe, a great deal of consolation for feeling 
that in some respects they are not so up to date as the 
visitor's. But this moving about keeps one alert and 
vigilant, and many good hints are picked up. 



20 OPERATING ROOM 

Few of the professional journals accord to the operating 
room a special section, and yet, to the man on the street, 
to the nurse, .and to the majority of the general prac- 
titioners who send cases in to a hospital, the operating 
room is "the whole thing. " 

On the first day of a pupil's term here the head nurse 
takes her through what has been hitherto forbidden 
ground, all the rooms belonging to the department, so 
that she may understand the "lay of the land," to find 
other persons quickly. She is introduced to all her fellow- 
workers in their respective capacities, scrubbed nurse, 
anesthetic nurse, so that the former, who is very much 
preoccupied, need not be disturbed for what the latter 
could just as well tell her. The successful supervisor 
gives her instructions in a clear, low, emphatic tone that 
reaches only the one it is intended for, and not too fast, 
at that. Frowns, signs, beckoning, or whispers are all 
very puzzling to novices, especially because they come 
up filled with terror, and are quite stage-struck and self- 
conscious at first. 

The Surgeon's Duty to the New Pupil.- To this novice 
every surgeon or anesthetist has an obligation, for she may 
some day be the brightest star in his firmament. Instead 
of ignoring and snubbing her, he should help her in every 
way within his power. The surgeon is so dependent on 
others for help that he ought to be sensible about building 
for the future. There will be times that a new pupil has 
to appear in the main room, that is, the most important 
of all the suite, but a clever supervisor will plan, as far as 
any human being can, to grade her work so that the novice 
is never confronted with any condition that she cannot 
completely master. To arrange so that the first thing a 
new pupil is seen doing she does well gives not only her 
but the surgeon confidence. But he should be big enough 
of soul to accept his share of the burden of training the 
pupils of the school, and to forget whether they are 
bright eyed or young, but to teach them, impersonally, 
calmly, and definitely. They will remember every word 



OPERATING-ROOM PUPILS 21 

he says, and it is much more profitable to say, "I always 
use ten-day chromic for the perineum," than to throw on 
the floor what she tremblingly hands him. Nothing 
depleted the ranks of the nursing force (i. e., in pro- 
portion to the increase in the number of hospitals and 
beds everywhere) like the oaths and throwing instru- 
ments about in the old-fashioned operating rooms. 

A new pupil should never be sent to look for an instru- 
ment in a moment of panic if she has never heard of it 
and has no mental image of it. When you lose your 
thimble, you will never find it if you think about pears. 
You must think "thimble." In these panics the instru- 
ment is not described graphically, the pupil fails to find 
it, and time is lost. Be ahead of the game. All those 
things must be laid out beforehand, in even the remotest 
possibility of being used, though they need not be boiled. 
They can then be easily pointed out. One of the most 
meritorious qualities developed in a careful operating- 
room training is forethought. It is far better to lay out 
too many dressings, or to open and thus unsterilize some 
special form of dressing, than to rush frantically for some 
in the middle of a critical operation. The surgeon has to 
bear all the responsibility of the case and its results, 
whether fatal or happy, before the visiting physician 
who sent it in, the relatives, the hospital authorities, and 
public opinion. It is criminal to leave him without 
good, reliable support in caring for the patient. The 
fact that some surgeon may be persona non grata is no 
excuse for sending him an incompetent pupil as assist- 
ant. If all questions are answered on the basis, "What is 
best for the patient?" or "How can we do the greatest 
possible good to the greatest possible number?" there will 
be absolutely no unfairness to any person connected with 
the institution, whether it be a surgeon whose ways are 
not modern, or a pupil nurse who uses too many ward 
dressings. 

Do not forget what the hospital is conducted to ac- 
complish — to cure the sick and to rid the community of 



22 OPERATING ROOM 

disease, unjust expense, and unhappiness. It does not 
exist for the purpose of training good operating-room 
nurses. That occurs if it does the other duty well. 

The Telephone. — There will doubtless be free telephone 
communication with the operating-room department on 
account of the interns' relation to the wards, the pres- 
ence of visiting doctors, and the calls of the surgeon's 
private practice. These calls must be very clearly taken; 
since it means money to the surgeon, and allaying the 
anxiety of the family at the other end of the wire, anxiously 
waiting. The supervisor, therefore, should keep a printed 
list of the names of the men who operate or view cases, 
and teach the new pupil the pronunciation of any difficult 
foreign names, so that she, being the superfluous nurse, 
may master them and take care of the telephone. There 
is one salient feature in all the training of pupil nurses, 
whether in a big metropolitan institution or some tiny 
suburban cottage hospital. They must roam about and 
learn the names of all highways and byways, so as to be 
familiar with the vicinity in which they work, on ac- 
count of calls for doctors, the addresses of patients, and 
speed in sending out the ambulance — in brief, the develop- 
ment of a strong business acumen. It should be the 
duty of this same nurse to keep pad and pointed pencil 
for instant use at the telephone, this extension being so 
important that it should be of the desk variety, fixed on 
a table or desk, and not on a wall. 

Some Ways of Arranging Work. — The most modern 
hospital methods include in the first few months' tuition 
of probationers, before they ever set foot on the wards, 
the making of all hospital dressings, for clinic, ward, or 
operating room, in which case they become very familiar 
with the names of all forms of gauze and cotton, i. e., 
wipes, compresses, fluffs, sponges, tampons, etc. This 
relieves the much busier, advanced pupil who is getting 
her operating-room training of a great deal of monotonous 
mechanical work, requiring no real professional skill 
and acting only as a sedative for a probationer's excited 



OPERATING-ROOM PUPILS 23 

nerves. "Let George do it" is a good motto in many 
respects for hospitals to apply to their internal economy. 
There must be developed accuracy, skill, honesty, un- 
selfishness along every line, but it is the rankest extrava- 
gance to make a second-year pupil sit folding gauze all 
morning and work then until midnight in the operating 
room, when dressings can be made by a probationer, a 
clean patient, or an orderly. It is quite usual for private 
patients, their special nurses, and their relatives to ask for 
some such thing to do. To ask a nurse to do what any- 
one less skilled can do just as well, after she knows how 
to do it well and quickly, wastes efficiency. The supply 
room should be separate from the rest of the hospital, 
though governed by the operating room, so as to regulate 
the amount of supplies as estimated from the operating- 
room records, where clean wounds, discharging wounds, 
and goods sold to physicians are all entered. 

Importance of Dusting. — But the principle of using 
unskilled labor where possible does not apply to dusting, 
or several other things that some nurses would like to 
evade. Dusting in a hospital is a scientific process that 
must be performed by one on whom the hospital can place 
responsibility for the success of its work. Orderlies or 
maids have no connection whatever with the results in 
a wound further than their own healthy condition, but 
nurses are to be held accountable for all those features, 
such as air, light, heat, and dust, that rank as accessories 
to the main act. For the simple reason that orderlies 
and maids receive no diploma, may leave at a second's 
notice, and have no comprehension of the meaning of 
bacteria, dusting must not be left to them, but be per- 
formed by a responsible person. Nurses are members of 
a class in society who, presumably, take pride in their 
work, who work because they know that labor is neces- 
sary to keep well and sane, who do things well because 
they are proud to excel, and who want to satisfy a grow- 
ing desire within themselves to attain more knowledge, 
more deftness, and more approval. The pupil who covers 



24 OPERATING ROOM 

a great deal of ground and takes long strides and strokes, 
occasionally letting things fall and break, is a menace, 
though her pyrotechnic displays may impress an on- 
looker whose judgment is shallow. But a pupil whose 
work behind the scenes is honest and enduring, who knows 
that the water in the sterilizers has boiled long enough, 
or that she positively has scrubbed every inch of the 
marble pit with Sapolio and Labarraque's solution, who 
remembers and attends to every detail of pin, pledget, or 
packing with meticulous care, is the foundation of suc- 
cess in surgery. It is peculiar and unfortunate that the 
opinions of doctors and supervisors seldom coincide about 
who is a good nurse. There is a sort of superficial smart- 
ness and precocity which take very well with surgeons 
during their hour of tense strain, existing probably 
because the pupil is rested physically, and has not fatigued 
herself by doing her whole share behind the scenes, or 
because she has naturally more self-possession, or more 
readily places herself in an impressionable attitude of 
mind to receive a telepathic intimation of the surgeon's 
wish. It is very rare, but does occur, that a nurse does 
her share of the rough work honestly and at the same time 
shows great skill and coolness with instruments. But 
passing instruments for a surgeon has nothing to do with 
teaching other nurses, or humoring the relatives of a 
private patient, or paying one's dressmaker and yet sav- 
ing money for one's old age. The ethical supervisor 
cannot decry the showy, dishonest pupil to the approving 
surgeons, but she must insist on thoroughness and com- 
pletion of all that pupil's share — no putting off until to- 
morrow what should be done today. The operating 
room must be completely ready in every respect at the 
end of each day. 

Some Difficulties which the Supervisor Has to Solve. — 
It makes a just supervisor's life very difficult to be at 
close range with a pupil whose tricky deceits make her 
feel uneasy about results, such as opening the autoclave 
too soon, or making up a hypodermic dose inaccurately, 



OPERATING-ROOM PUPILS 25 

knowing all the while that this pupil is getting credit for 
cleverness from people who are easily fooled by show. 
Frank talk and constant checking up, combined with a 
nice judgment of human nature, a generous allowance 
for youthful vanity, and quick approbation for attempts 
to improve may help correct these obnoxious conditions. 
Otherwise they become a festering sore in the heart of 
the remaining pupils. s 

There is a special gift in handing a surgeon what he 
wants without having to be told, but it is governed by 
certain important factors. One must first know every 
inch of the operating-room suite. This is gained by 
daily dusting, putting supplies away, and taking inven- 
tory. Second, one must have in mind an accurate, ana- 
tomic picture of the operation to be performed. This 
must be taught before each kind of case to the pupils 
who will take part. Then, third, one must have all the 
goods required generously supplied in a systematic way 
on the sterile tables. Fourth, the workings of every screw, 
lever, and button on instruments, cautery, or lights must 
be thoroughly known beforehand, learned in quiet lesson 
hours and practised to get speed, without an audience. 
To control the welfare of pupils or patients by these 
methods gives the shy nurse an equal chance, and elevates 
the operating-room supervisor's position to a lofty degree. 

Sequence of Instruction. — After the pupil has been 
introduced to every hole and corner in her new scene of 
labor, she should be quizzed to find whether she took in 
what she saw, so as to form the habit of observation: 

(1) What rooms adjoin the operating room? 

(2) Where is the oxygen kept? 

(3) Where is the normal saline? 

(4) WTio is anesthetic nurse? 

(5) Which is the hot- water sterilizer? 

(6) How many stands are in the scrub-up room? 

In making these rounds the head nurse should frankly 
point out existing difficulties — to watch for the backward 
swing of a certain door, to keep screens in all windows, 



26 OPERATING ROOM 

to swat flies, to keep steam out of the main room or to 
reduce noise — always showing what would be an ideal 
condition to foster in these minds the ideas that will 
result in finer construction and equipment in future, 
hospitals. Couple work with hopeful imagination. 

Routine Cleaning. — In teaching the pupil to dust the 
method should coincide reasonably with that employed in 
the wards — soap and water and two dusters, with Bon Ami 
smeared on glass to dry. The supervisor demonstrates 
the direction of movement, beginning in corners and com- 
ing to the center; the system of going around a table or 
chair rung after rung in orderly rotation, not hither and 
yon, so that, if called away, one knows where to start 
again, since in this department everything must be 
covered completely, not just the seemingly dirty spots. 

Dusters of various kinds are needed, stout, soft-made 
cheese-cloth dusters for rubbing soap or Bon Ami on, 
brushes for Sapolio, and thick, dry, lintless cotton cloths 
for drying and polishing. In the hopper room are kept 
all articles for damp work; therefore this room must be 
well sunned and aired. Each nurse should dust her 
own section of the operating-room suite, so that it is all 
finished early. The new nurse is not a drudge or a Cin- 
derella. If she spends all morning cleaning while nobody 
else does any, the place is not in order on time, and she 
is not learning any the ways in which she should become 
instantly useful, a fleet-footed messenger. Mops, brooms, 
and brushes belonging to each worker are kept separate, 
so as to be easily checked up or found. It is wrong to 
ask an orderly to do an}^ scrubbing higher than the floor 
or lower than the chandelier. In any case, he should be 
well supervised. 

In whatever section the pupil nurse is placed, whether 
new (and "dirty"), anesthetic, or scrubbed, she should 
constantly observe what the one next highest has to do. 
The average hospital has three pupils on this service for 
from six weeks to three months each, giving them from 
one-half to a whole month in each of these sections above 



OPERATING-ROOM PUPILS 27 

named. Three or four days are enough to become sub- 
consciously familiar with routine duties, so as to cast a 
free eye on the work of one's immediate senior, because 
emergencies of every kind will be conducted well by this 
acquisition of knowledge. 

Utensils and Linen. — The next lesson is in the care of 
utensils, but not of instruments delicate in construction and 
difficult to obtain. It is wrong to place the instruments in 
the hands of a greenhorn. She who passes instruments, 
knowing which and how many she has laid out, must put 
them away, with help, of course, to break in her juniors 
who usually get through before her, but so that she may 
carry the responsibility of their count and condition — 
especially keeping them in a fixed place on the shelves 
that everybody will know, and in an order that has some 
anatomic science at its basis. But the new nurse may 
scrub basins, baskets, tubs and faucets, and sort linen 
for the laundry, washing off all clots before it goes down 
the chute. By cooperation with the laundry a strict 
check can be kept as to who let an instrument go down 
the chute, a small pillow, or a rubber sheet, particularly 
when, as a disciplinary measure, the lost articles are 
returned via (1) the superintendent's office, and (2) the 
superintendent of nurses' desk. At many more times 
in the day than from the other chutes the laundry clears 
away the linen from the operating-room chute, which 
should be situated separately from the others where they 
debouch on the lower floor, and by the hours when it is 
emptied and by the articles found strict account can be 
held of the nurses on duty at that time. "Make haste 
slowly" with linen, instruments, and anything else in 
hospital equipment, for all of it is of untold value when one 
wants it and has not any chance of getting it. A repri- 
mand for such carelessness should be enough, but, if fol- 
lowed by a repetition of the offence, the supervisor would 
be justified in withdrawing some of the pupil's privileges 
or honors. The superintendent of nurses is deeply con- 
cerned here, and is not truly fulfilling the obligations of her 



28 OPERATING ROOM 

office if she is afraid or too busy to visit the operating 
room often and know all its workings. The operating- 
room supervisor is beneath her in rank and the two must 
work in unison. A new superintendent of nurses cannot 
expect to change all the operating-room methods, to the 
dismay of the surgeons, deepened, perhaps, by the innuen- 
does of an inethical operating-room supervisor. Both 
women would be at fault. The newcomer must study 
the situation first in its entirety, and only where it is 
inefficient, if she is clever enough to detect it, should she, 
by cooperation with the surgeons, correct the faults on 
the basis that her pupils must get the best training to be 
had. It is no longer necessary (to return to the point 
whence the digression was made) to count linen daily. 
A modern building is so equipped and laid out that linen 
cannot be stolen from it. The employees file out of one 
door past the offices, and cannot carry bundles or pad 
their persons without exciting suspicion. The supplies 
for operating are of a different texture, pattern, and make 
from the ward goods, and are marked distinctly. Ward 
supervisors finding operating linen in their stock should 
return it to its proper place at once, and report the same 
to the head laundress, to have the error in her depart- 
ment corrected. The "dirty" nurse who sends down 
the linen should, as a part of her training, see it through 
the laundry a few times, and have charge of it when it 
comes back, so that, knowing now exactly how long it 
will take, she can keep tab on every piece. When the 
patients are taken to the ward, every blanket or towel 
must be brought back and sent down the operating-room 
chute, not the ward chutes, lest time be lost owing to 
their less frequent service. A ward pupil "receiving" 
the ether patient must go over her with a fine-tooth comb 
to learn her condition so minutely that she pounces at 
once on any foreign body such as an operating-room 
chest blanket or pus-basin. 

Building the stretcher is a lesson for the first day. In 
all lessons the supervisor, demonstrating, emphasizes 



OPERATING-ROOM PUPILS 29 

the points on which former pupils failed, and after doing 
the actual work, watches the pupil do it over. If the 
latter makes mistakes, she must do it again until she 
does it properly. 

Classes in Anatomy. — The new "unscrubbed" nurse 
need not be kept entirely out of the anatomic features of 
the cases. She is present each morning at the small class 
held by the supervisor before a skeleton and a set of 
anatomic charts in the work-room, where, briefly but 
tersely, she sketches the site of each wound, hernia, 
cholecystectomy, or iridectomy, going more minutely, 
perhaps, into it with the nurse at the instrument-table. 
Here she builds for the future. The best supervisor is 
she who turns out the best finished products, "good 
futures' ' in operating-room nurses, as they say in the 
cotton market. It is not by isolating herself to fold cool, 
unimpassioned linen, talking with interns, making rounds 
through the wards, playing politics with the surgeons, or 
doing all the hard and delicate skilled work herself that 
a supervisor helps the hospital most fully. When pupils 
read these pages let them be assured that the hardest 
days they spend on this service are the days of which they 
will be proudest by and by, indeed, as soon as they get 
rested. 

No head nurse can teach all she knows. No Latin 
master can give his pupils 'all his knowledge. But the 
hints and suggestions from attendants and interns who 
have watched many other operators and visited many 
other operating rooms should be heartily welcomed. 
No pupil can absorb all she hears. It would, therefore, 
be a sorry world if there were not a good safe way to avoid 
these two glaring defects. Make the pupil self-reliant. 
Do not try to cram her mind with facts, but teach her 
how to know when she is ignorant, and where to go for in- 
formation. There are charts, books of rules, anatomy 
and materia medica text-books, surgeons, and nurses to 
consult when she is in doubt. 

Impartiality. — Nurses in the operating room should not 



30 OPERATING ROOM 

be bribed or coaxed to lend themselves to the especial 
aggrandizement of any one surgeon. The doctors should 
maintain a strictly impersonal, business relation with them, 
and vice versa. Favors arising in the operating room to 
one man, though bestowed by a pupil, cause fusses all 
over the institution. A pupil must know that she is not 
to be swayed by emotion here above all places in the 
hospital. She must do for one only what she does for all, 
whether it be lending instruments, giving out supplies, or 
rendering more devoted service herself. There are rules 
written and unwritten that must be observed to keep an 
honorable course and a clean conscience. To act fairly 
and squarely toward the Directors, the Medical Board, 
the hospital staff, and the municipality is the largest and 
noblest interpretation of good operating-room work. 

Relation Between the Operating Room and the Ward. — 
Operating-room work is studiously omitted in most state 
requirements, and yet it is the chief work of some private 
nurses going out to "set up," assist, and care for the 
patient until she is "over the operation." Others make 
a livelihood as office nurses where all minor surgery is 
performed. As the heads of clinics, others yet have to 
command as much knowledge of surgery as the retiring, 
secluded operating-room nurse. The superintendent of 
nurses must be familiar with all these fields, and have a 
secure feeling that her pupils are being equipped for 
these things so as to reflect credit on her. 

One tactful pupil can dissolve the antagonism of years 
between wards and operating room by helping out the 
former in the thousand little crises that daily occur in this 
earnest life. (1) If a ward is anxious to have "hot things 
hot" for a case in shock as it goes down, she can keep 
them posted by phone as follows: "They have just finished 
sewing up." (2) If a surgeon intends, after operating, to 
do some difficult "stunt" on the ward, which is not ex- 
pecting it, she can telephone to that ward, "Dr. is 

going to snip the frenum under Baby 's tongue, or 

retract the foreskin, or ligate his extra thumb," because, 



OPERATING-ROOM PUPILS 31 

on the other hand, it is a very mirthful moment on the 
wards when the operating-room forgets a sponge or a 
piece of drainage. If a pupil in her first six months has 
shown qualities that do not make for integrity and in- 
dustry, endurance and foresight, she should be denied the 
training. Why tantalize a valuable supervisor? Why 
vex a surgeon? Why endanger a patient's life? 

After reprimands, if the pupil makes good, let her 
take the training. If again, during the first weeks of her 
operating service, she falls from grace, pursue the same 
course. Many pupils have gone through their hospital 
work in a mechanical way; but such is the genius of the 
American people for organization that the modern girl 
catalogs what the hospital has to offer before entering, 
and asks for what she fears she wall miss. Many girls' 
training has been absolutely unbalanced, too much 
night or medical or surgical work, and this is wrong. 
But they all endow with some very mysterious honor the 
operating-room service, and they ought to earn it, getting 
it preferably at the end of the first year. 

Deportment. — The pupils must be of military deport- 
ment in obedience to each other, according to rank, in 
the matter of work, at the same time preserving a humane 
friendliness in the matter of help and privileges. It is 
not fair — and the supervisor should step in here — for one 
nurse, who is very fond of going out, to "trade nights" 
with a conscientious "drudge" who has no place to go; 
nor should one plead "malaise" or "migraine" oftener 
than another. When a pupil from the wards w r hich may 
seem extravagant comes up to beg for dressings, she should 
not be met with savage looks. If her ward uses too 
much, its staff should come after hours and help make 
them or help sterilize them. The same thing may 
happen when they are in reversed positions. Besides, 
there should be limitless supplies for drainage cases, 
such as fecal fistulse, gall-bladders, and "pus appendices," 
which the operating staff should inquire about and 
study carefully. 



32 OPERATING ROOM 

Eight-hour duty is just as possible in an operating room 
as in a ward. There are more pupils needed for this 
system in any ward or division. The chief argument 
opposed to it is "responsibility/ 7 but on account of the 
minute subdivision of all labor it means nothing. Miss 
A. can scrub up and come in to relieve Miss B. on instru- 
ments as soon as she knows "where the surgeon is at," 
silently and unobtrusively, just as well as any other time, 
as long as the supervisor remains through the case. 
Where the pupils are of vastly unequal skill, operations 
should be booked with this in view. For night work 
there should be pupils on the wards who "have had 
operating room" and can "take" any emergency. The 
supervisor should not have her rest broken year in and 
year out, with such meager pay that she cannot insure or 
pension herself. The pupils always do well, and the doc- 
tors help them more when left to themselves. Some 
hospitals put a nurse on regularly from noon to midnight 
to bear the brunt of the night work. 

Priority of service on a ward comes before seniority 
in the school when an operating nurse relieves. The ward 
nurse may be a junior, and yet have all her ward affairs 
at her clever finger-tips. An operating-room pupil who 
may go there for a half-day or a Sunday should fit in grace- 
fully, bowing to the judgment of the superintendent, the 
power behind the throne, instead of sulking, loafing, or 
picking faults. 

Certain hospitals have given their most capable pupils 
scholarships in cash, from $50 to $100, as pin money to 
use while taking postgraduate work by the gracious con- 
sent of some large recognized institution which receives 
the outsider and gives her her chances, home, and ac- 
commodations in return for her labor. This gift fre- 
quently comes from the private treasure of one member 
of the board, but it is a good practice to establish in all 
schools, for all grades of work, through the auspices of the 
whole body of governors. Some nurses may be averse 
to surgery and yet wish to devote themselves to the care 



OPERATING-ROOM PUPILS 33 

of children, and they should stand an equal chance of 
such a scholarship. 

Self-government is a priceless boon to the nurse — as 
inaugurated in many Western universities — and a vote 
by the nurses, serious and well-pondered, should be a big 
factor in awarding these scholarships. 

All visitors, whether confessors or messengers, must be 
received with courtesy, and the burden of their being in 
that "Holy of Holies" placed on the office, where it be- 
longs. This is a part of the nurse's training to "get along 
with the relatives" in private work. So great is the bond 
of affection in some families that the lonesome cry of the 
dying must be answered despite red tape and frowning 
walls: "Come with me, granny, come with me! I canna 
gang alone!" — and granny says, with brave eye, but 
trembling lip, "I'll gang wi' ye, laddie, as far as ever I 
can." 

Genito-urinary Work. — It has been at different times 
and in different states a burning problem whether pupil 
nurses should be present at genito-urinary operations 
(male cases). The surgeons of the old school are the ad- 
visors of today, and having had their experience in the 
old-fashioned way, where the nurse was present at all 
operations, the gist of their counsel is to do the same 
with the modern pupil. Why not leave it to the option 
of the pupil? She is a separate entity, and need not take 
the whole of the system prescribed for her, holus-bolus, by 
people who do not know how a woman feels, especially 
since the whole operating-room period is omitted in the 
schedule of some states for nurses' training. In any 
university a man has the option of classics or modern 
languages, science, or arts. The future career of a nurse 
can decide her present choice for her. If she wishes to do 
army and navy work, district work, etc., she may decide 
to study genito-urinary work, and the opposite holds 
equally well. The ward work acquires no new skill from 
the fact that the nurses are present at these operations. 
The anatomic nature of these cases is such that the rigid 
3 



34 OPERATING ROOM 

asepsis of abdominal cases is not applicable or necessary. 
Besides, orderlies can be taught to become quite skilful 
in waiting on the surgeons, and if reliable and well paid 
remain steadily on the staff, much more to the surgeon's 
advantage than the changing pupils. The extreme 
youth of the average pupil at present must be considered, 
too, in comparison to the age of the nurses of ten or 
twenty years ago. When the nurse is doing private 
duty after graduation she seldom if ever "specials" a 
"g.-u." case outside of hospital walls, and this work is 
usually assigned by any thoughtful superintendent to 
the older women, for many good reasons that need not be 
specified. Why, then, force this part of operating-room 
work on an unwilling pupil? The work can be easily 
cared for in the operating room by interns, who will un- 
doubtedly have in their future office practice a very large 
percentage of this work, and who are. naturally very 
eager to learn to relieve these conditions. Then, again, 
in private practice, a nurse following this branch of 
work is alone with her patient, while a surgeon always 
provides himself, in gynecology, with the chaperonage 
and assistance of an office-nurse or a relative to protect 
himself from slanderous tongues, just as much as to pro- 
tect the patient. These questions are entitled to discus- 
sion by impartial modern minds of lay committee mem- 
bers as well as surgeons. 

Moving Pictures. — By a little additional expense a 
moving-picture system can be established in the operating 
room for the education of the pupils, in which the field of 
operation is shown every inch of the way, also the in- 
strument table, so that a nurse can easily learn why she 
must provide certain instruments and dressings. It will 
soon be possible, when a supervisor presents the day's 
schedule, to turn on a reel and a phonograph simulta- 
neously, to see the actions and hear the explanations of a 
surgeon removing a ureteral calculus, or performing a 
herniotomy, or again, transplanting a graft from a tibia 
to a spine for Pott's disease, ununited fracture, or to an- 



OPERATING-ROOM PUPILS 35 

kylose a knee-joint. The nurse who has to "set up" for 
a certain case will be enabled to see just when the 
"spurters" will spurt, so as to know when to hand a liga- 
ture, or to see when the bone-dust ("sawdust") flies, so 
as to lay anew a sterile towel. This is the only way to 
solve the ancient difficulty voiced in a plaintive tone by 
thousands of nurses: "But I never can tell what he is 
doing!" 



CHAPTER II 

THE JUNIOR NURSE 

"Life is a patchwork quilt, stitched on the background of Eternity, 
and padded out with the rags of Time. Strange colors we introduce! 
Here a dash of scarlet Passion, there a scrap of pure white Faith, 
then brown Doubt and pale green Ennui ! Most of us, however, 
have to fall back on the dull drab of Work to fill out the spaces, 
and thank God for it, for it rests the tired eyes." 

Quoted from an old, old issue of Toronto "Varsity"; student 
author unknown. 

Her Numerous Duties. — This nurse's work seems 
hardest because it is new and apparently disconnected, 
a heterogeneous mass of "chores," a bewildering waiting 
on four people at once, all of whom equally insist on im- 
mediate notice, waiting for others to pass, finishing up 
what others begin, and jumping at every one's beck and 
call. Yet the "floater" is indispensable. 

She must dust with a damp gauze cloth and a dry 
linen or cotton one, Bon Ami, and brown soap in all the 
rooms appointed to her — the sterilizing room, hopper 
room, dressing rooms, etc. — the anesthetic nurse doing 
her own portion and the scrubbed nurse the operating 
rooms. A marble pit should be scrubbed with Sapolio 
and dilute Labarraque's solution at the finish of each 
day's operating. She scrubs all basins with Sapolio 
and dilute Labarraque's solution, or, if rusted in spots, 
lets them stand at a slant, with a weak solution of oxalic 
acid until this disappears. (Oxalic acid must be kept in 
the poison closet.) She assists in moving unconscious 
patients aiid puts on binders or bandages, trying to show 
perfect skill in applying what she was taught in previous 
classes. She should be able to do it well before coming 
to the operating room, so as not to keep a patient on the 
stretcher until vomiting begins. In handling these 
36 



THE JUNIOR NURSE 



37 



things on the stretcher long footstools must be used. 
A nurse cannot get any "purchase" on her work if she is 
too far above or below it. She may be asked to "set up" 




V^ 



Fig. 1. — Offering a glove case. 



for cases shortly after entering on this service by clean- 
ing the tables with carbolic acid (5 per cent.), then selecting 
and opening the proper table covers, and, after donning 
her cap, scrubbing, and donning a gown, laying these 



38 OPERATING ROOM 

covers in place. Teaching the junior to "set up" early 
facilitates running off a full program. She waits then on 
the instrument nurse — opening jars, collecting empty 
covers, tying gowns, and keeping everything picked up. 
In fastening gowns she touches no part of the garment 
but the tape nor the doctor's fingers. In removing sterile 




Fig. 2. — Sterilizer forceps for removing basins from the utensil 

sterilizer. 

goods (Fig. 1) she holds them out from her body, and never 
carries a bundle under her armpit. She brings in the 
boiled instruments, holding them firmly at a distance 
before her, and not setting them down (for she would have 
to reach over a sterile cover), but waiting for the nurse to 
take them. She carefully washes all instruments that 
fall on the floor and boils them the right length of time, 



THE JUNIOR NURSE 39 

specified in the house book of rules, with her eye on the 
clock over the sterilizers, from time to time looking in to 
see if she is needed in the main room. Forceps are to be 
used in lifting basins out of the utensil sterilizer (Fig. 2), 
so that a nurse's body need not hang over it. She may 
hold a sterile basin without letting her fingers come 
over the edge of it (compare with a well-taught maid 
handing one a dish of preserved fruit). She fills this 
basin with sterile water, holding it on her palm, first 
under the cold tap, second under the hot for her own 
comfort, and away from her body, so that possible 
dandruff will not drop in. These solutions should be 
tested by a glass thermometer kept in a disinfectant, 
lifted with forceps, and rinsed with sterile water before 
plunging into what may go on the eye or on the bowel. 
If it is too hot it will burn the patient or the surgeon; if 
if it is too cold the patient will be "shocked," and at the 
surgeon's language she herself will be shocked. She 
drops a sterile towel by means of the same sterile forceps 
over the arm tank of bichlorid when all are through 
immersing. She must never take anything off the sterile 
tables. The scrubbed nurse must drop them to her or 
hold them so that she can grasp them in a forceps. She 
must think with every bit of her outer clothing., i. e., by prac- 
tice she learns to judge distances, so as not to hang over 
or back against anything (Fig. 3). She takes nursing 
charge of the patient the moment the anesthetic nurse 
leaves, giving the anesthetist all the supplies he needs, 
and administering hypodermics at his order carefully and 
correctly, charting over her signature all the data regard- 
ing same. 

She washes and boils every instrument inadvertently 
dropped, and in bone-plating, which demands most rigid 
asepsis, she resterilizes every instrument every time it is 
used, therefore keeping the small sterilizer boiling. She 
learns early to run the cautery, practising without a 
patient. 

Sponges now are, fortunately, not counted, owing to 



40 OPERATING ROOM 

the speed of operating. A surgeon may put one sponge 
in the vagina as backing while suturing, but it should be 
simply a "coup d'esprit" to remember it. It is quite an 
honor to be asked to remember a plug or pledget some- 






t 



A..,. .,., 



Fig. 3. — Wiping perspiration from a scrubbed nurse's brow. 

where, and one does as easily as an invitation out to 
dinner, but to ask a nurse to count and handle a hundred 
bloody or pus-laden sponges was never right or necessary, 
especially for two reasons: (a) it took her mind off all the 
instructive details; (6) they bore infection. 



THE JUNIOR NURSE 41 

She must turn to the blanket warmer if the patient goes 
into shock for warm wraps to restore him. 

She should be put in the Trendelenburg and the Sims 
positions herself and then practise with the fattest women 
she can find, so as to learn where to adjust their knees, 
hips, etc. She must also wind up the table, if the anes- 
thetist's mind must be confined to the anesthetic alone, 
though the modern tables make it easy for him. She 
wraps the patient's feet in a hot blanket so that they will 
not cool in mid air. She must learn by experience to 
judge how long she dare stay out of the main room when 
boiling up, going back to the patient, watch in hand, 
rather than be missing when needed. The surgeon 
should never be the one to insist on getting an instru- 
ment before it is boiled long enough. 

After a case is concluded all the work is moved up a 
notch. She washes and changes the linen on the operat- 
ing-table, where only one is used, gathers up all linen, 
throws bloody linen under the cold tap, puts on the 
binders, cleans basins, then if she knows how (it has been 
already recommended) scrubs up, and "sets up" while 
the senior nurse selects other instruments, wraps and 
boils them, and "scrubs up" later. 

She keeps the scrub-up stands clean and supplied with 
brushes at all times. Dry sterilization and plenty of 
brushes obviate the difficulties formerly noticed in boil- 
ing so many kinds of things between cases. 

She must keep looking around for something to do. Caps, 
masks, gowns, suits, towels, bandages, etc., are all replen- 
ished, and sterile sheets for the next case, which, how- 
ever, are not opened until the supervisor begins to scrub, 
and which, also, are limited by arrangement to fixed 
numbers. She cleans the sterile tables with carbolic 
acid 1 : 20 before they are reset. The operating-table 
is the last thing to be used (where the patient is anes- 
thetized on a stretcher), and the supervisor need not be 
foolishly overdriven by anyone in a false haste of prepara- 
tion, aiding herself by somewhat postponing the cleaning 



42 OPERATING ROOM 

of this important piece, the changing of pillows, and wip- 
ing of the pad. 

The dirty nurse puts on binders. It is very essential 
to have all sizes of good binders in sufficient numbers, 
and they must be properly applied, for surgical reasons. 
Obstetric binders press down from above. For lapa- 
rotomies, they press upward from below. They must be 
measured around the widest part of the body, the curve 
of the hips, and all fittings taken from that point, darts 
carefully put in both below and above the hip curve to 
keep the pressure on the dressings secure. This is accom- 
panied by a T-binder for vaginal work, which has a slightly 
different model for male patients, being split. The 
safety-pins should be rowed around the edge of a piece of 
Castile soap. 

An ordinary Sloane breast-binder with a sleeve added 
makes an excellent binder for breast amputations. 

After a first case the room should be cleaned and read- 
justed like magic if everyone knows her duty. The 
bichlorid solution in the arm tank is changed for a new 
operator, but not for a new case, unless used during the 
progress of a pus case. 

The sterile basins for hand solutions are changed for 
every case. Nothing used for one case should be used 
for the second, or touch anything that will be used later. 
If a heavy smear of blue chalk is put unnoticed on a 
door knob or some other common object frequently 
handled by all the force, it gives a valuable lesson in the 
transmission of invisible bacteria. 

The unscrubbed nurse watches visitors, presents them 
with armless gowns, and sees that they do not come in 
contact with sterile tables. 

The shoulder-pieces for Trendelenburg are puzzling 
at first sight, but easily thought out. They must be 
well padded to prevent bruises or paralysis of the trape- 
zius muscle. The bar running into the rings must be well 
nickel-plated, rustless, and lubricated. The stirrups must 
be similarly inspected and kept perfect. The loops of the 



THE JUNIOR NURSE 43 

foot-rests must be perfectly understood, the arch of the 
foot resting on one half, the tendo Achillis on the other. 
The angle in each stirrup, directed outward, is to throw 
the patient's limbs farther apart to give the operator 
more room. In lithotomy, the patient's buttocks must 
hang over the end of the table so as to relax all the soft 
parts, and the Kelly pad should not slide down too far 
when the patient is placed "in situ." The apron of the 
pad must fall from the angle at which it is made. 

The unscrubbed nurse may have to record the number 
of pairs of gloves or tubes of catgut used in an operation 
if the office makes specific charges to the patient for 
these. 

As several operations succeed one another with great 
celerity, and the specialists desire to take home their in- 
struments, the junior nurse must at this period learn the 
mechanism of every cautery, cystoscope, tonsil snare, or 
rheostat. Then she can, with the probable aid of the 
anesthetic nurse, clean them and put them together while 
their owner is in the shower-bath and the next case safely 
started. It helps greatly to have them soaking in cold 
water to loosen bloody particles, but this does not apply 
to some parts of a cystoscope, etc., that are never wet. 
While one case is being sutured, the scrubbed nurse should 
hand her junior all the instruments that will be needed for 
the next except the suture set, to be washed and started 
boiling. In a busy operating room much time is saved 
by putting each surgeon's instruments into separate large 
basins, of which there should be many, if they cannot be 
immediately cleaned, tagging each basin with the name 
of their owner. It is very easy, by using the brain be- 
hind one's eyes, to learn each man's instruments, but it is 
impossible if one's mind is on plays and dances during 
work hours. 

By dusting, the junior learns where everything is and 
acquires the "location" habit. 

She must instantly provide boric acid and argyrol if 
pus squirts into the surgeon's eyes, and carbolic acid and 



44 OPERATING ROOM 

alcohol with a clean probe if he jabs his finger with a 
needle. 

When patients require catheterization, she saves the 
specimen, and marks it at once with the patient's name, 
not daring to trust her memory, whether she is told to do so 
or not. In cystoscopic work, she marks the left and right 
specimens with perfect accuracy, knowing this involves 
life or death for the patient. 

She stands with the specimen basin (given her without 
contact by the scrubbed nurse), holding it from below, so 
that if the surgeon inadvertently touches it when he lays 
down the specimen he shall receive no contamination from 
her. Dermoid cysts, fetuses, and all other solids are 
saved as a routine, and preserved in formalin (4 per cent.). 
Getting this habit prevents one from absent-mindedly 
throwing away some priceless thing. 

She can instantly procure sandbags of the right shape 
and size to adjust a head or limb to the surgeon's fancy. 

She slaps ice towels on tonsil cases to restore con- 
sciousness and good circulation, or to relieve hemorrhage. 
She deftly turns the tonsil cases in their special long rubber 
sheet (2 yards by \ yard) so that they bleed into the pail 
at the surgeon's feet, where he may look for specimens 
and judge the amount of bleeding. 

She prepares all solutions, irrigations, douches for hem- 
orrhage, enemata, etc., and must be sure of her formulae 
and accurate in their temperature, using a sterile ther- 
mometer every time, kept in a harmless antiseptic solu- 
tion and plunged into the fluid by sterile forceps. 

She is the logical person to prepare for intravenous 
infusion, lumbar puncture, or hypodermoclysis "on the 
table" without any agitation or mistakes. 

After a long ether anesthesia she brings the lavage 
set, with a bucket for the return, and a pan of ice-water 
for a lubricant. This is also usual in peritonitis cases. 

When she gets a hint that the patient will be a drain- 
age case she asks if a Gatch bed will be used, and tele- 
phones this to the ward, so that the ether bed will be al- 



THE JUNIOR NURSE 



45 



tered in time for all to be in complete readiness when he 
goes down. This avoids delay in making him comfortable, 
and is much easier than with a stretcher beside the bed 
when the change is effected in the ward. 



%# 




'■& ;. • 



TO; 



Fig. 4. — Dusting aristol on a wound. 

She telephones general messages to the office or ward 
at the will of the surgeon or intern, or writes (and initials) 
orders in the ward order book at their dictation, vised by 
the anesthetist. 

She keeps work going on all the time behind the scenes 



46 OPERATING ROOM 

— linen soaking, washing or drying gloves, sorting covers 
as she takes them out, or running the big sterilizers. 

She must drop acetanilid, aristol, or collodion on a 
new wound in an aseptic manner, wiping off the con- 
tainer with a bichlorid compress, and delicately winding 
a sterile towel around her right arm (Fig. 4). 

She puts on any tourniquet for amputation or intra- 
venous infusion, knowing the anatomy of the parts. 

She is instructed by the engineer personally about all 
lights, switches, fuses, valves, stop-cocks, faucets, cold 
coils, water jackets, steam jackets, pet-cocks, foot-treads, 
gages, sprays, soapholders, waste-pipes, traps, and other 
forms of steam-fitting, plumbing, and electricity, accord- 
ing to a list drawn up by him and the supervisor. When 
nurses are. taught these things it reduces the stoppage of 
pipes, etc., to almost nothing. 

She must shave an emergency case or one improperly 
prepared "dry" with a steady hand and in a perfect 
manner. This necessitates frequent practice on the 
wards previously. 

If there are flies in the vicinity they must be swatted 
(the woven wire bound in velvet being best), and all 
doors must be closed during a case. 

When the "unscrubbing" nurse cleans the instrument 
cabinets she learns where to find things in a hurry by 
then asking what each is, and for what it is used, each 
shelf having its list of contents on a card lying in one 
corner, in the order in which they are found, from left to 
right. She replenishes the basin of calcium chlorid now 
deliquescent, used to keep down the humidity. 

She has a stock there, too, of smear-glasses, slides, and 
swabs ready for immediate use. 

In genito-urinary cases the scrubbed and junior 
nurses wait on the operator from behind screens. In 
hernia no expose is necessary if extra towels be used 
under the laparotomy sheet. If nurses are excused or 
protected by a screen, they must render excellent assist- 
ance none the less. 



THE JUNIOR NURSE 47 

Black rubber tracheotomy tubes, ivory-handled knives, 
etc., must not be boiled in a moment of thoughtless haste, 
ruining the shape of one and the material of the other. 

The junior nurse must listen avidly to the words of 
every actor in this drama, but not to others. By know- 
ing what they say she can make a shrewd forecast about 
what they will want next. 

The junior class is given instruction in bandaging, 
even in their preliminary training, and they must practice 
on each other, on convalescent patients, and on the sick 
patients finally, timing themselves, and working under 
inspection, so that they can put on any bandage in the 
operating room if necessary. In the past it has been 
so badly done that the surgeons do it themselves, not 
hoping to find anyone who can. 

When the supervisor habitually "scrubs," the junior 
is put in a hard position, being unable to confer with her 
in a crisis. She must whet all her senses to ten times 
their previous sharpness, remembering that here not the 
nurse is in charge, but a man who is under great tension 
due to the bigness of the stakes. He may only jerkily 
ejaculate his needs and get angry if not understood. 

The junior nurse is the "eyes and ears and feet" of the 
staff, who may not leave their places. She must know 
their thoughts, and feel with their sense of touch, and see 
with their vision. 

After a laparotomy, when vaginal drainage is desired, 
the operator slits the culdesac of Douglas, and passes 
down a piece of drainage (never from below up) into the 
bite of a uterine dressing forceps held in the vagina by the 
junior nurse with a gloved hand. This sterile glove must 
be ready. The nurse cannot do this well if she has not 
an accurate idea of the relative position of the bladder, 
uterus, and rectum. It requires a drawing or chart in the 
supervisor's morning lesson. 

A small bunch of twigs (especially birch) is useful in 
whipping out the fibrin of blood-clots when searching for 
specimens. 



48 OPERATING ROOM 

To give an enema in haste the set should always be 
in readiness. 

Washing soda should not be used in aluminum pans, 
nor on the aluminum handles of instruments. 

A patient should always be protected from the cold 
rubber of a Kelly pad by a large soft towel. This pad is 
thoroughly scrubbed after each case and soaked in 
bichlorid. Some surgeons think it is never "clean." 

When messages come in from the outside the junior 
nurse must transmit them exactly, realizing their im- 
portance for the doctor or the family needing him. There 
should be a pad of typed blank forms for this at the tele- 
phone. 

Perspiration in the axillae is inexcusable. The nurse 
must bathe twice a day if necessary, use plenty of un- 
dented powder, and wear shields washed daily and dried 
in the sun. 

For her own benefit, to save back-bending and for the 
cleanliness of everything she handles, garbage cans should 
open by a patent foot-tread. 

Special Beds. — A case in which the bladder has been 
accidentally slit requires special instructions to the ward 
about making the bed. The top and bottom sections of a 
three-piece mattress are used, but in the center are laid 
four pillows longitudinally (two deep and two on each 
side), so that when she is laid on her face the retention 
catheters drop through into a urinal tied in the center 
of the spring beneath. The pillows are each covered with 
rubber, and the whole bandaged into position. The same 
holds for certain fracture cases in the disposal of a bed-pan. 

For a Murphy drip the nurse can most easily get at 
her patient if the covers are divided in the center laterally. 
Protect the patient with a soft warm covering. Take 
four old blankets and fold each in half laterally. Spread 
a sheet over the bed, and on its upper half lay two blankets; 
then bring up over them the bottom half of the sheet, 
tucking it under their upper edge, and its under edge out 
over all as usual with any counterpane. Lay another 



THE JUNIOR NURSE 49 

sheet over the bed, its bottom edge reaching barely to the 
edge of the mattress. On its lower half lay the two 
remaining blankets, and turn the sheet down over them 
in order to tuck it in at the foot. Pin the two sets to- 
gether over the patient's hips. This permits any ad- 
justment of a Murphy drip, etc., without disturbing the 
patient, and is excellent for a colon irrigation. Being 
ordered from the operating room it slightly concerns this 
chapter. 

Gatch beds may be improvised by a back-rest, a pillow 
with a rubber cover to sit on, a small board under it on a 
long sheet folded many times over, diagonally, into a sling 
fastened at the head of the bed frame, extra pillows for 
the back and arms, to rest on, and a rubber-covered pillow 
under the knees. A second long sheet sling with a folded 
sheet may be used as a foot-rest, tied to the parallel bars 
under the spring. The quick transmission of sugges- 
tions for such a preparation facilitate the maintenance of 
very friendly relations between operating room and 
ward. 



CHAPTER III 

THE ANESTHETIC NURSE 

Positions for Operation. — This nurse's duties are so de- 
tailed that she will seem to need a whole book to herself. 
She first learns how to place patients in the various 
"positions" required for operating from demonstrations 
by the supervisor on the living subject. There are always 
convalescents in the women's ward who enjoy being thus 
honored. There is no use in preparing a patient for a 
position until she is thoroughly relaxed by her anesthetic, 
i. e., when the anesthetist gives the order. Then it can 
be done quite easily. It is better to call for assistance 
than to take too long or to maul the patient about, since 
the tissues are most easily bruised when one is under an 
anesthetic. Some patients are very obstreperous, there- 
fore wide bandages, sheets, etc., for mild restraint must 
always be at hand. Neither nurse nor orderly should 
throw himself across the abdomen of a struggling patient 
whose appendix is about to rupture. The restraint neces- 
sary must not be applied to the diseased part. Some most 
mysterious bruises, high on the shoulders — e. g., in an ap- 
pendix case — can only be accounted for by having forced 
the patient down on the table. 

(1) Dorsal Position. — The patient is flat on her back, 
but her knees are flexed, so that her heels are near and on 
a level with her hips. 

(2) Kidney Position. — The patient lies on her face 
with her arms above her head, and a cylindric rubber 
bag inflated with air under her abdomen, to push up the 
kidneys. A badly placed kidney rest annoys the surgeon, 
delays the operation, and possibly cuts off the patient's 
respirations, while the anesthetic nurse gets a black mark 

50 



THE ANESTHETIC NUKSE 51 

in anatomy. If the patient's arms are under her body 
paralysis may ensue. 

(3) Sims Position. — Always to be used in giving ene- 
mata except where a wound prevents it (and then only 
with the doctor's permission to do differently). The 
patient lies on her left side, her left knee drawn partly up 
to her chin, her right knee farther still — this opens up the 
way to the rectum and vagina. The hips and knees must 
form a straight line, parallel with the end of the table, and 
hanging slightly over it. A real Sims table has an ex- 
tension on the left side for the feet. Her left arm is 
gently drawn out from before her breast and placed 
behind her, at the right of the table. Her chest should be 
flat on the table and her face turned to one side com- 
fortably. Her right arm is above her head. 

(4) Lithotomy Position. — The patient lies flat on the 
table, drawn down with the Kelly pad so far that her 
buttocks will hang over the end when the foot is dropped. 
Each foot is hung up in a stirrup which has a strap hang- 
ing from a snap, making two loops, which pass (1) up 
behind the heel and (2) under the instep. The screws of 
the stirrups work simply and must be kept well oiled, 
but they must be practised on before a patient reaches the 
operating suite. It is very wearing on a surgeon's temper 
to have to ask every day to have the patient "brought 
down a little further." The stirrups must always be 
kept in one conspicuous place. 

(5) Knee-chest Position. — The patient is not anes- 
thetized. She kneels on the operating-table as near the 
foot as possible (for cystoscopy, etc.), with her face down 
on the table and her breast down to her knees. She needs 
support from beneath her abdomen. 

(6) Trendelenburg Position. — When a patient is placed 
in a recumbent position for a gynecologic operation it is 
well to expect a call for Trendelenburg. Her knees must 
be about 2 inches below the joint in the table, so that when 
the shelf drops the bulk of her calves will not prevent her 
knees from dropping parallel with it. Her limbs must be 



52 



OPERATING ROOM 



securely pinned in a warm woolen blanket about one 
yard square, brought around from behind them, caught up 



1 Hjj 





Fig. 5. — Gwathmey gas-oxygen apparatus. 



at the feet into a pocket, and pinned in front. Her 
shoulders are rested against two shoulder props which 
must always be newly and fatly padded to prevent 



THE ANESTHETIC NURSE 53 

paralysis of the trapezius muscle. The modern table is 
wound up or lowered at the anesthetist's will, and it is 
positively his business to notify the operator that he 
must lower her if she is "going bad." But the nurse her- 
self should be placed in Trendelenburg by the super- 
visor, and should also learn all the mechanism of the 
table. There should be a pad for the table of rubber 
filled with air and hair, and with boxed edges, to pre- 
vent the patient from rolling off. The best method in 
any operating room is to prepare the patient on the table 
which the surgeon will use, and roll her in, all ready. 
This avoids lifting her once when anesthetized. It also 
prevents any of the customary awkwardnesses of arrang- 
ing her on the table while every doctor waits. This sys- 
tem, of course, requires two tables of the same kind that 
are used in any special operations, but anything to save 
time is a gain. 

Setting Up the Anesthetic Room. — The anesthetic 
nurse sets up her room with the various kinds of ap- 
paratus for anesthesia, the inhalers for gas-ether, gas- 
oxygen, or other anesthetics (Fig. 5), the tripods for gas 
tanks, the usual sizes of face masks, cones, or masks for 
chloroform and ether, according to the "drop" method 
and the- "open" method, vaselin or K-Y for the patient's 
skin, bandages, and means for restraint, binders, chest 
blankets, large blankets, sheets, cloth stretchers (i. e., 
small stout double sheet, 1\ yards long by | yard wide, of 
unbleached muslin, used in lifting), chloroform, ether, 
pins (straight and safety), a jack-knife to open ether cans, 
pus-basins with a high wall on the outer side to prevent a 
spray of vomitus, towels, sponges, mouth-wipes, two 
sponge forceps, tongue clamp (Fig. 6), tongue suture, 
mouth-gag (oral screw — Fig. 7 — of black rubber), scratch 
pad and pencil, wrist watch for herself, pocket light, 
oxygen tank and its fixtures, stomach-tube, rubber cap 
for the patient's head or "ether" cap made with a towel 
(Fig. 8), bed-pan and urinal for nervous patients (with 
proper covers of muslin), special unsterile sheets for drap- 



54 



OPERATING ROOM 



ing, triangles, extra large towels to lie between the tri- 
angles temporarily, bandage scissors, pads of gauze and 
cotton fitted to the eyes and bridge of the nose to pre- 
vent "ether eyes," and lastly, the stimulation tray. 

The stimulation tray should contain only the drugs used 
during operations: (1) Morphin; (2) atropin; (3) strychnin; 

(4) digitalin; (5) whisky; (6) 
brandy; (7) camphor. 

These are excellently pre- 
pared for emergency use in a 
form called the Greeley units, 
consisting of a small glass 
tube containing the dose 
specified on a legible printed 
slip, as strychnin, gr. -§V, a 
needle ready for injection, 





Fig. 6. — Tongue „ 

rubber tips 



clamp with soft- Fig. 7. — Mouth-gag. Oral screw, 
r tips. hard rubber or boxwood. 



but protected by a sterile cover, and a small soft metal 
collapsible tube (on the principle of a cold cream tube) 
which, when squeezed, forces the fluid dose through the 
bared needle. There should be a large assortment of 
doses of each of these on hand. The drug, camphor, 
should always be kept in ampoules, and the small files 
coming with them must not be lost. Their contents are 
more easily drawn into a hypo, syringe from a sterile 



THE ANESTHETIC NURSE 55 

spoon than from the ampoule itself. The glass of the 
ampoule must not be broken. The speed and the ac- 
curacy of the dose are two potent advantages in using 
ampoules and Greeley units. 






\ 



Fig. 8. — A serviceable "ether" cap for all purposes. 

The anesthetist's cap, jacket, and trousers are, of 
course, laid out in the dressing-room used by the surgeons, 
and need not be sterilized. 

To produce speed in work there should be on the 
supply table of the anesthetic room a standard number 



56 OPERATING ROOM 

of articles of each kind, so that when the pile is reduced 
one can tell at a glance how many of each to get again. 
They should always be in a fixed order or grouping, so as 
to facilitate their instant selection by all. This is no 
place for a nurse's individual whims. When a valuable 
suggestion can be made, however, there is a correct time 
to do it and a correct way, that is, modestly, when the 
day's work is done. Otherwise all must follow the same 
routine. 

When the patient arrives in the anesthetic room she is 
asked whether she has any false teeth, loose teeth, crowns, 
or bridges in her mouth, any hairpins, false hair, jewelry, 
or artificial parts, which all interfere with her own phys- 
ical safety under anesthesia. The wedding ring may be 
tied on with ^-inch tape, one knot in the ring, one double 
knot at the back of the wrist, and another below the 
palm. 

Patients may desire to void urine again, through 
nervousness or long delays, and it cannot be reiterated 
too loudly or too often that a full bladder is a very danger- 
ous condition under the knife. Free urine in the ab- 
domen acts as - a highly poisonous foreign body, the 
patient sometimes dying from absorption, while, on the 
other hand, the bladder walls heal slowly. 

It is a solemn thing to a whole family when a patient 
takes an anesthetic. What nurse covets the opportunity? 
Put yourself in the patient's place. Do not talk while 
she is going under. The best anesthetic nurse will 
have a certain calm assurance, kindness, and dignified 
cheeriness that must be worn at all times, even when the 
operation will possibly prove fatal. The anesthetic nurse 
may be the last person the patient will ever see or the 
last one to whom she will speak. To the patient herself 
and to the family loss of consciousness is the big thing, 
not the operation at all. Most of us dread the conse- 
quent helplessness, and would bravely endure any pain 
to be allowed to know what was going on. The frequency 
of assisting and the almost universal success of all the 



THE ANESTHETIC NURSE 57 

cases must not make a nurse treat them lightly, not even 
a child. It is a well-known fact that doctors and nurses 
are the worst sort of patients. 

The gown must be loosened at the neck to permit dis- 
tention of the blood-vessels during the period of excite- 
ment. The noise made by filling the gas-bag in the gas- 
ether apparatus should be got over with before the pa- 
tient's eyes are covered. No delay is permissible after 
that. By good careful inspection of the apparatus 
leaks, etc., are detected. There should always be a reserve 
stock of ether and gas-bags with other rubber goods kept 
in a cool place in lycopodium or other powder. The 
patient must not be left alone for one moment from the 
time of her arrival in the anesthetic room. 

The orderly who brings up the stretcher should disap- 
pear at once. He should not be seen by the women 
patients afterward. It makes them fear that he will be 
present during the operation, where, of course, he is never 
allowed. He may be called to assist in lifting the patient, 
though that is not necessary when she is anesthetized on 
the operating-table. Forethought and good executive 
ability are required to think out and define the detailed 
duties of each member of the company before the play 
begins. 

The nurse may have to bestow sundry petty attentions 
on the anesthetist, especially if he be a stranger, but they 
are minimized by having everything in order on the 
supply tables. A good anesthetist will try to deflect the 
nurse's attention entirely to the patient and find what he 
needs before beginning the anesthetic. 

In transferring from the operating-table to the stretcher 
(1) the anesthetist lifts the head and shoulders; (2) the 
anesthetic nurse and the orderly the middle of the body 
by means of the small stretcher sheet; (3) the operating- 
room "dirty nurse" the feet. 

Similarly, in putting the patient to bed, these rules hold, 
except that the receiving nurse takes the feet. It is 
wisest to have no stretcher for special cases — run the oper- 



58 OPERATING ROOM 

ating-table to their bedside and take them upstairs on it. 
Again, some common cases of appendicitis, etc., are 
lodged in the bodies of highly nervous people, who wish 
to be anesthetized in the operating room, where they may 
face the worst. Let them have their way. Where an 
anesthetist ungallantly shirks in his share of the lifting, 
imperilling his patient's respirations, the operating 
surgeon should reprimand him. If he does not see it, 
the supervisor should report him. Lifting at a higher 
level than the point of one's greatest strength is not 
necessary or conducive to good health in women. Unison 
should prevail in points like these, but the supervisor 
should be granted especial authority to note and mention 
details of this sort, to "break in" new men, tactfully, of 
course, and always on the basis of the patient's best in- 
terests. The anesthetist counts "one, two, three!" and 
on "three" everyone lifts. 

The arms require especial care at all times. In transit 
on a stretcher, they should be pinned on the chest and 
kept in place by the blanket, always brought up from 
beneath. In the dorsal and recumbent positions they are 
(1) placed parallel with the body, or (2) brought up above 
the head. 

Problem of Nurses Giving Anesthetic. — Some nurses 
try to get as far away from nursing as possible after 
receiving their diploma. Among these are some "nurse 
anesthetists." The pupil "anesthetic nurse" watches the 
pulse for her own information only, but when asked what 
it is, should state the truth. Nurses never dissect nor 
vivisect, and cannot tell the deeper actions and reactions 
of chloroform or ether. It seems absurd, therefore, and 
dangerous too to qualify them as anesthetists and en- 
trust them with lives to just as great a degree as the man 
with the scalpel. If a "nurse anesthetist" finds a pa- 
tient "going bad" she cannot legally prescribe a hypo- 
dermic or an infusion. It is true that she may have a 
quicker intuition and sympathy with the patient, but this 
cannot be charted or justified in a court. Then, again, 



THE ANESTHETIC NURSE 59 

what counts for more, she works for a low salary, much 
less than a physician's, and she cannot take any ana- 
tomic interest in the surgical procedure to distract her 
attention. But these factors cannot conscientiously 
atone for the dangers she creates by her ignorance. If a 
patient dies under an anesthetic given by a physician 
the relatives accept the situation philosophically, not 
dreaming to dispute his skill, but if in a nurse anesthetist's 
hands, what then? Then, too, nurses should not lend 
themselves to the exploitation of human flesh, unpardon- 
able in any profession. A corporation should not make 
an ill-proportioned profit out of the services of any skilled 
employee. If a nurse anesthetist gives ten anesthetics 
per day at $10 each, and receives a salary of $60 per 
month, she is exploited like a slave, and, worse still, she 
helps the system along. 

As soon as one case is well begun the anesthetic nurse 
arranges the stretcher and leaves. There should always 
be a binder of proper size on it for abdominal cases, so 
that they may be rubbed clean and dry, and lifted to the 
stretcher to be finished up. To facilitate putting on the 
binder rows of safety-pins are kept in Castile soap. 

In odd minutes, waiting for an anesthetist, the nurse, 
if industrious, should make hundreds of yards of packing 
(Fig. 9). Before she is called to the third service, of 
"scrubbed nurse/' she talks with the senior as they clean 
instruments together after cases, discussing how many of 
each and why all were used, or may help clean instru- 
ments so as to send them away with their owner after his 
case is over. 

Oxygen may be conveniently handled in small tanks 
that can be lifted in one hand, or stand on a low 
tripod, like the nitrous oxid tanks. The large oxygen 
tanks can be rolled from place to place, first removing the 
fixtures. To administer oxygen properly is not difficult, 
but it is a source of many mistakes. A gauge can be 
bought at any first-class instrument maker's, and by un- 
screwing the nozzle for the fixtures, this may be screwed 



60 OPERATING ROOM 

on. It is a dial, which when opened shows at once how 
many pounds' pressure remain in the tank. All oxygen 
tanks in the hospital should be regularly tested, and there 



^3 5 



/ 



Fig. 9. — Making packing from a bandage. 

should always be one or more full tanks in reserve, ac- 
cording to the number of beds. The oxygen weighs next 
to nothing. One cannot tell by any means but the gauge 
whether a tank is full or empty without wasting it. 



THE ANESTHETIC NURSE 61 

But it is expansive to the pushing strength of 250 pounds 
in the largest size of tanks provided for hospital con- 
sumption. On the tank hangs a bottle of clear glass con- 
taining clean water always fresh. Through the rubber 
cork go two bent glass tubes. The tube running down the 
lower must be under water. It is connected with the 
tank, and the oxygen must be forced into the water for 
three reasons: (1) It detects a leak; (2) it moistens the 
oxygen and renders it fit to breathe; (3) it helps us regu- 
late the flow — it should be given at the rate of three 
bubbles showing. 

The shorter glass tube is connected with the patient. 
If this is reversed, the water will be blown all over the 
place and the oxygen wasted. By using the gauge before 
and after, on certain cases, the amount used can be 
estimated and charged for at the hospital cost of 1 cent 
per pound. In ordering oxygen be sure to state that it 
must be odorless. If stored in stables it is very un- 
pleasant. The distance of the factory from the hospital 
is a factor determining how soon to order again. 

A small catheter well-lubricated except in the eye, or 
specially made flat nose-pieces of black rubber are best 
for ordinary stimulation, the funnel method having gone' 
into disfavor. A lighted match shows that by the funnel 
method the oxygen ascends to the ceiling. 

All oxygen face fixtures must be boiled and sunned 
after using, since in many cases they were used for lung 
diseases. The pneumococcus or tubercle bacillus could 
be thus directly transmitted if no prophylaxis were ob- 
served. 

After the Operation. — The anesthetic nurse accompanies 
the patient to her bed, and goes over her thoroughly with 
the ward nurses to show that she has delivered her to 
them in good condition. She collects all her basins, 
blankets, etc., and returns to the operating room at once, 
to boil all masks, pus-basins, etc., before using them for 
another case. 

The chart accompanies the patient downstairs, with 



62 OPERATING ROOM 

a slip fastened to it containing the important details of 
the operation. It may be used for reference during the 
case. If the patient has not voided before the anes- 
thetic, this is reported to the surgeon by the anesthetic nurse, 
since she was the last one to converse with the ward 
nurse. It may be on the chart, but it must be verbally 
reported. 

Tonsil cases are laid face downward on the stretcher 
when being taken to bed, with their arms above their 
head and their faces slightly turned for air, in order to 
swallow no blood. 

Some very skilful surgeons keep drainage appendix 
cases on their face also, and the results are good. 

The anesthetic nurse has several true nursing duties 
while in charge of her patient: 

(1) She must keep him warmly covered, bringing up 
one blanket from below his body, then covering him with 
a head cover and a chest blanket, pinning his neck closely 
so that no air will get in while his pores are opened with 
ether, and pinning his sleeves to his chest to prevent frac- 
tures while in transit or being lifted to bed. 

(2) She watches for hemorrhages and vomiting. 

(3) She sees that the bed is clean, warm, and dry, and 
that there are no hot-w r ater bottles anywhere in it; also 
that the rubber drawsheet was not superheated by them, 
to burn him. 

(4) She learns how to hold the jaws to prevent a pa- 
tient from swallowing his tongue, downward and back — 
practising on the class skeleton. 

(5) She learns to sponge out mucus. 

(6) She administers amyl nitrite — now prepared in 
dainty silk and lint covered tubes all ready to crush, the 
lint absorbing it, instead of the piece of gauze that was 
never at hand — the old-fashioned pearl was crushed in a 
piece of gauze by a firm hand or a weight, and held a few 
inches from the patient's face. 

(7) She learns how to do artificial respiration slowly 
enough — 16 strokes to the minute. 



THE ANESTHETIC NURSE 63 

(8) She prevents burns by the use of a face lubricant, 
a hospital cold cream preferably. 

Special anesthetics require a note here. Spinal anes- 
thesia, a fascinating experiment, is seldom used, but has 
its special outfit. This is performed with the strictest 
asepsis, if such can be, on account of tapping the cord 
and putting germs in possibly with the anesthetic. The 
Medical Board should render decisions about anesthetics 
to be purchased and prepared by the hospital and its 
staff for ward cases, but for private cases each surgeon 
will be allowed his choice, within reason, at his patient's 
expense. Fads must be kept out. The good name of 
the hospital is in the trust of the Medical Board. An 
error of any sort in the choice of anesthetic should lead 
to a searching trial. 

In rectal anesthesia the nurse's duties are prominent. 
She gives the enema — olive oil, gvj; ether, gij — mixed in 
an enamel graduate with a funnel, rubber tube, glass 
connecting tube, large male catheter lubricated, and an 
artery clamp, all these articles standing in a neat basin 
with a covering. The patient's face is covered, so that 
he rebreathes what his lungs eliminate. Then, after the 
operation is complete, the amount not yet absorbed is 
siphoned off with a larger tube (rectal) and the bowel 
flushed with cool water and soapsuds. One ounce of 
ether and three of oil are used for every 75 pounds of 
body weight. 

Chloroform and ether deteriorate if exposed to air, 
and must be bought in containers as small as possible — 
ether, in J-pound cans; chloroform, 40 grams. In be- 
ginning a new case an anesthetist must open a new bottle. 
To carry it on, most men will use the left overs from a 
previous case. If not, use these ends for cleaning, keep- 
ing them in two stock jars. It is especially good for 
grease marks. Chloroform, ether, and ethyl chlorid must 
not be allowed to evaporate. That is wasteful. Chloro- 
form masks may be covered with flannel, which is boiled 
after every case, "thus getting so hard that it must be fre- 



64 



OPERATING ROOM 



quently renewed. Anything more open of mesh will let 
drops through. 

The pulmotor (Fig. 10) requires skilled care in cleaning, 
especially in not confusing the parts and closing off 
the wrong channels, but can be operated by anyone. 




Fig. 10. — The pulmotor. For resuscitation of the apparently 
lifeless from the effects of anesthesia, poisonous gases, smoke, drown- 
ing, electricity, collapse from any cause. The operator applies a 
face mask and turns a key, starting the mechanism of the apparatus, 
to produce immediate and measured respiration, with pure oxygen 
entering the lungs at each inhalation. The tongue is held forward 
by forceps, and oxygen prevented from entering the esophagus by 
pressure with the right hand (Da Costa, Modern Surgery). 



All syringes, as for spinal anesthesia, must be very 
thoroughly cleansed with cold water after containing 
human serum, which, if cooked, will ruin their working. 

Pus-basins for vomitus should have a high outer wall. 

The anesthetist should have a certain position for his 
table of supplies. When the nurse is coming in with the 
patient the orderly may carry this table to its place and 
provide him with his high stool. 



THE ANESTHETIC NURSE 65 

The anesthetist is sometimes covered by a sheet, 
and must be especially assisted in small ways. When 
holding a child for staphylorrhaphy the nurse is also 
covered with a sheet, and should get some special atten- 
tions, since nothing is to be gained by smothering her in 
her own C0 2 . A harelip infant recovers more smoothly 
the sooner it is operated on, and is held with its arm- 
pinioned in a small towel up against the nurse's breast 
and neck. 

To pin up a child, use a large face towel, or a small 
double muslin sheet made for such purposes. Lay the 
towel about its hips, the long edge horizontal, and pin 
once in front. Pin the child's cuffs together over its 
stomach, thus folding its arms down. Reverse the towel, 
so that it rises toward the head. Pin straight up the 
front. Then make darts of equal size on the shoulders. 
5 



CHAPTER IV 

THE SCRUBBED NURSE 

This nurse has fewer duties assigned her, but requir- 
ing much skill, physical endurance, patience, and the 
crystallizing of all she has previously learned to focus it 
on this particular case. A nurse in this position must 
keep good hours, wear sensible shoes, and conserve her 
energy so as to have a clear head and not give the wrong 
kind of needles or sutures. To save time the "dirty 
nurse' ' may cleanse the tables with carbolic acid solution 
(5 per cent.) and unpin all the packages to be used in setting 
up, while the senior puts on her cap and scrubs to set up, 
finally donning gloves and, as some insist, a gown. She 
spreads the covers on the tables, so that the part going 
over the edges is the last she touches, being pushed from 
her. She stands as far as possible from the table, so as 
not to let her gown, bib, or apron come in contact with it. 
Having set all her basins, etc., in order, she removes her 
gloves, scrubs again, dons her clean gown and new gloves. 

The junior brings her the tray of boiled instruments, 
held away out before her, the senior using every such 
opportunity to teach her asepsis. The instruments should 
always be disposed on the table in a routine way, so that 
one may pick up a clamp without looking to bite a 
spurter. 

Routine is not always to be adhered to, however, be- 
cause it kills originality. The scrubbed nurse fastens 
the first four towels in place with towel clamps for the 
skin preparation, handing the assistant a sponge stick and 
a glass of iodin, followed by alcohol, which she does not 
receive back. She again fastens a set of towels around the 

66 



THE SCRUBBED NURSE 67 

operative area, is assisted in placing the laparotomy sheet, 
and over it places four towels again, laying them on up- 
side down, clamping at the upper edges, and then pulling 
them over, right side up, so that the towel clamps will 
not get mixed up with the operating instruments. She 
puts the scalpel, sponges, artery clamps, and mouse- 
tooth forceps on the towel, then swings her small instru- 
ment table into position, and the case begins. She washes 
blood off all instruments, keeps a supply of wipes and 
sponges, offers hot saline on tape sponges when the intes- 
tine is exposed, not after, offers ligatures, sutures, etc., 
noting all her mistakes (and vowing that they won't recur) 
until the case is completed. She must know the laws of 
ligatures and sutures, needles and instruments (a) from her 
text-book in anatomy; (b) from the book of house rules; 
(c) from the surgeon's own words; (d) from the text-books 
on operating-room work. 

Sutures. — The surgeons will frown on extravagance 
as a bad omen for the pupil's private work in future, 
besides for their patient's bill, since the scrubbed nurse 
is supposed to count the amount she uses and charge it to 
the case in some institutions. The nurse must calculate 
it to an inch, and report all data, so as to enable the hos- 
pital to buy closely, so many short lengths of each kind, 
etc. 

Long-handled Needles. — A special long-handled needle 
has recently been invented to sew up a hemorrhagic area 
after tonsillectomy. 

Small Needles. — Thread them quickly. Cut catgut with 
a bias end, and know the needles, whether they have the eye 
at the side or back. Twist the thread on itself once or 
twice at the eye, after threading, and it will lie flat, place 
in the needle-holder one-third from the eye, the point 
projecting to the left for a right-handed surgeon, and 
hand to him with one bend of the wrist, throwing the 
handle into his palm, the mouth pointing back to the 
nurse, who catches the flying thread in her second and 
third fingers to keep it taut. As to shapes and their 



68 OPERATING ROOM 

uses, the head nurse makes up a sample card for in- 
struction. 

Needles for syringes should be slip-ons, since they are 
clean and easily worked. They must always have a 
stylet. Special needles for lumbar puncture have an 
eye, and the point of the stylet is bevelled. 

Knives are right and left for throat work. If the edge 
has a full curve it is said to "belly." Blades set in a frame 
— e. g., the tonsillotome — come under the classification of 
knives in their care. A paracentesis knife for myrin- 
gotomy must have two blades, and go through the small 
end of any ear speculum. 

Ligatures. — These are chosen according to the size and 
toughness of the part, their time for absorption, and the 
size and importance of the blood-vessels involved. They 
must be cut long enough for each and every operator to 
hold in a firm grip — i. e., 9 inches. 

Scissors are selected with a view to the anatomy of the 
part and the operator's hand. They are blunt or sharp 
pointed, straight or curved, curved on the flat (right or 
left), or curved upward, long or short. 

Forceps are straight or with handles, plain or with 
mouse teeth, pivot, screw-lock or mortise-lock, corru- 
gated or smooth, corrugated crosswise or lengthwise, 
straight, angular or specially curved, and of varying 
lengths. There are also special kinds of forceps: (a) 
placenta, (b) obstetric, (c) gastroenterostomy, (d) gall- 
stone, etc. An artery clamp has such an important duty 
that it should never break, and the inferior molded forceps, 
though cheap, must give way to the superior though ex- 
pensive "drop-forged" forceps. 

Instruments generally should be known by their pur- 
pose, not by the inventor's or maker's name. They are 
chosen for operation according to its location, the depth 
of the wound, and the shape, size, and weight of the organs 
involved. Even then many must be covered with 
rubber tubing or buttons of soft rubber in order not to 
crush a delicate part — e. g. y the intestines. 



THE SCRUBBED NURSE 69 

Operators have many idiosyncrasies which must be 
mastered and noted in the book of house rules, as to what 
position best suits them, the height of the table, the sort 
of gloves, whether they are left-handed, or have lost a 
finger, etc. An old-fashioned table can be heightened by 
setting it in four pieces of iron gas-pipe of equal length, 
below which again are the casters. 

Instructions in Conducting an Operating Room. — 
The scrubbed nurse receives her instruction in buying 
by visiting the office with the supervisor when she makes 
her weekly requisitions, as well as by discussing costs, 
materials, and makes while at work. On the spindle in 
the workroom is placed every item of goods running 
short, goods criticised by the operators, instruments they 
asked for, or anything else relating to the work of oper- 
ating. 

• She collects all instruments for repair, sharpening or 
renickelling, under the supervisor's approval, and packs 
them for mailing, knives in their boxes, padded with the 
cheapest cotton, scissors rolled in the soft paper which 
came the week before, and all listed as to size, shape, and 
needs. One slip goes with them and one is kept in the 
main office, but the original list is made in the book for 
repair of instruments which is not destroyed, since it 
shows how certain kinds stand wear, while others may have 
to go too often to the repair shop, etc. The Instrument 
Committee is chosen from the surgeons, and they have 
control of the buying. Under the supervisor's direction 
she visits the wards, examines their instruments, ships 
them for repair, but never sends the only two of one kind 
at one time, and carefully decides about what to discard 
permanently. She takes all the night operations in some 
hospitals where the night force does not contain a nurse 
who "has had operating room." The supervisor should 
not have to take night cases, since it is most essential 
that she should have a clear mind and a rested body at 
all times. This induces the capable women to retain these 
positions. There should not be such a great disad- 



70 OPERATING ROOM 

vantage created in any one sort of position. The pupil 
may also relieve the supervisor for her time off. When it 
comes to vacations, the selection of a relief nurse comes 
before the hospital staff. She should be one acceptable 
to all branches of the service. 

. A little dissection of animals, fowl, and fish in the 
main kitchen under the direction of the dietetian 
makes a useful complement to this service for the 
scrubbed nurse, and proves just as interesting as it is 
useful. 

The scrubbed nurse has charge of the plaster work, 
which is discussed in another chapter. She also looks 
after the cutting of gauze, rolling bandages, making 
dressing-covers, and the general work of getting sup- 
plies, watching three things: (1) the every-day supply, 
sterilized and circulating; (2) a reserve of sterilized goods, 
always kept up to a fixed, written standard; (3) a huge 
unsterile reserve of made-up goods, cotton, gauze, and 
muslin covers, so that there may always be plenty, no 
matter whether there be (a) a breakdown in the sterilizers; 
(&) an unusually large number of operating and pus cases; 
(c) or some epidemic among the nurses. 

The scrubbed nurse sharpens her commoner instru- 
ments with strop and hone, or oil stone. She tests all 
instruments for sharpness, rust, bite or spring, making 
a drumhead out of the wrist of an old glove over an 
embroidery hoop for edges. If it cuts smoothly, the 
knife is sharp; if it is uneven, the knife is dull. 

Business, — All parcels bear addresses, which should be 
carefully noted and memorized. Catalogs of the leading 
firms amply afford interesting and instructive study 
material through their illustrations. 

Ambulance bags should be under the control of the 
operating room (unless the ambulance room has its own 
graduate nurse) so as to unify the supplies, especially of 
instruments. The bag should be sent up by the intern 
who rides the ambulance each time anything is used in 
it, instantly replenished, and instantly returned. The 



THE SCRUBBED NURSE 71 

special emergency goods for it are tourniquet, cord tape, 
cord instruments, mouth-gag, hypodermic set, packing, 
and small oxygen tanks. Here again is registered a pro- 
test against hospitals making their own catgut, since it 
has nothing whatever to do with a nurse's private duty. 
General Hints. — 1. Be sure to lubricate vaginal or 
rectal specula. 

2. All thick heavy instruments must be thoroughly 
cooled in a deep basin of sterile water. 

3. The scrubbed nurse must be ready to assist at the 
wound when called. 

4. Slides, smear-glasses, etc., for specimens are kept 
in their own basin, apart. 

5. Applicators must be wound correctly — 

(a) So as to be fluffy at the end. 

(b) So as to come apart easily. 

(c) Cleansed by a second piece of cotton. 

(d) So as to bury the end of the instrument so 

that it cannot inflict a wound. 

6. Silk-gut sutures must never be buried. 

7. Improvise a weighted speculum with a pail of water 
(quart) on the Sims. 

8. Do not carry bundles of sterile goods near the 
body, better use a tray. 

9. Practice taking the wires out of a tonsil snare. 

10. If the nurse is left handed, she must correct that 
in passing instruments to a right-handed man. 

11. She must instantly recognize the instruments 
owned by each surgeon on the staff — 

(a) By the make. 
(6) Shape. 

(c) Age and condition. 

(d) Numbers on the parts. 

12. Note the numbers on all clamps, knives, etc. 

13. Use instruments to work with, at the sterile table. 

14. When the surgeon says, " There is one sponge in the 
vagina/' don't let him forget it. 

15. Wash the patient, dry her, and rub with alcohol 



72 OPERATING ROOM 

and powder, looking for burns from iodin, bruises, etc., 
before applying the binder. 

16. See that the dirty nurse puts the binders on well, 
and have plenty of them, properly made. 

17. Large abdominal retractors must be warmed to 
100° F. to prevent shock. 

18. Hand solutions that are too hot burn the doctor's 
hands and delay the operation. 

19. Irrigating solutions must have an infusion ther- 
mometer inclosed in a connecting tube to show their 
temperature. 

20. Chloroform seals rubber tissue for a neat skin dress- 
ing. 

21. Have very many clamps for breast amputations 
and vaginal hysterectomies . 

22. If called to sponge, press once deeply on the bleed- 
ing area (except the eye, an ulcer, or an appendix about 
to rupture) until the surgeon's hand approaches, then lift 
quickly. 

23. Keep a generous stock of all sizes of sand-bags. 

24. Keep a number of Politzer bags and plenty of rubber 
dam for cholecystectomy and rib resection for drainage 
by suction. 

25. When aristol is shaken over a wound, see that the 
dirty nurse does so, with a wet bichlorid towel around the 
shaker and her own wrist. 

26. When a Murphy button has been used for intes- 
tinal anastomosis, a very special notice must be issued by 
the scrubbed nurse to the ward nurses, and the "button" 
should be the subject of general comment until it is 
found (Fig. 11). 

27. All pus, etc., must be confined to the towels on 
which it fell, and passed on to the other nurse to be disin- 
fected. An effort is made to keep all dirt in as narrow a 
space as possible, and to make it harmless at once by dis- 
infection. 

28. Needles should be boiled in perforated metal 
(nickel) boxes (about 4 x 2 x 1| inches) for safety as 



THE SCRUBBED NURSE 73 

to number, care of the points, and the nurse's finger- 
tips. 

29. Loose silk may be drawn into gauze before boiling. 

30. Needles may be threaded with silk and drawn into 
gauze before boiling, or dry sterilized in flannel. 

31. A man run over by an auto is a clean case, and yet, 
off the street, may have received the tetanus germ into 
his blood. At the first hint from the surgeon, the scrubbed 
nurse, listening intently, passes the suggestion on to the 
junior to get the hypo, ready for injecting antitetanus 
vaccine. 

32. The points of needles require constant testing. 
Never boil up a dull needle. Test after boiling. Never 




Fig. 11. — Murphy anastomosis button, round, with center collar. 

hand a surgeon a dull needle. Keep a large stock to 
select from. 

33. Scissors are tested on cotton. If they make a 
clean cut, at the tip first only, well and good. Then try 
the whole blade. Look for a gap between the points. 

34. Artery clamps must fit exactly. If they are too 
loose or too tight someone will have to pick them from 
the floor where the angry surgeon threw them. 

35. Always put the surgeon in good humor by laying 
down a sharp scalpel for him to begin with. 

36. Pivot, mortise, screw (applied to clamps, scis- 
sors, etc.). See in instrument catalogs. A nurse's 
bandage scissors have a mortise lock, slipping into place, 



74 OPERATING ROOM 

a cleft over a bar, on the bias or bevel. A pair of household 
scissors have a screw lock. A pivot is a straight bar pro- 
jection, fitting at right angles into a hole. All joints must 
be oiled after cleaning, and the oil may be boiled with 
them. 

37. When a second case comes on, the scrubbed nurse — 

(a) Sorts her instruments and adds what she had 
previously selected for the second case, clean- 
ing and boiling them. 

(6) Counts the used gloves into a basin. 

(c) Removes gown and gloves and scrubs. 

(d) Puts on new gown and gloves and "sets up" 
with the aid of another nurse, who opens drums 
or packages, or she does this herself before 
scrubbing. 

(e) Sets up, and asks for instruments to be 
brought in, which she cools, sorts, etc. 

(/) Is all ready with iodin, sponge stick, doctors' 
gowns, gloves, lap sheet, etc., when the others 
arrive. 

38. The instrument nurse must wash and soak her 
gloved hands frequently during the progress of the 
case. 

39. All tape sponges have a tape loop which is slipped 
into a heavy metal ring that hangs around an abdominal 
wound — this eliminates the hateful sponge count. 

40. Sutures classified according to how they are taken, 
run in, and cut: 

Guy. Temporarily put in with a long loop for 
traction in place of using vulsella. 

Lembert. In and out at one side of the intestine, 
skipping the wound, and in and out through 
skin on the other side. 

Through-and-through. Stout silk or silkworm-gut 
on long, heavy curved needle through the skin 
and deeper layers at once (but not the peri- 
toneum). 



THE SCRUBBED NURSE 



75 



Tier. Each layer by itself: 

(a) Peritoneum — fine catgut on small round 

body full curved needle. 

(b) Deep muscle — chromic gut, interrupted. 

(c) Deep fascia — catgut. 

(d) Skin — catgut, silk, gut, or adhesive only. 
Buried. Never to be visible again; in deeper 

layers, and not involving the skin. 

Running. One thread inserted several times 
without cutting. 

Interrupted. Knotted and cut at each insertion. 

Tension. A very long suture beginning several 
inches beyond the wound and passing through 
the skin and deeper layers. 

Continuous. See Running. 

Pursestring. A silk suture in the intestinal 
tract to invaginate a raw area (the stump of 
the appendix, for instance), on a straight fine 
cambric needle, all the way round in two direc- 
tions, and poking in the raw gathered flesh, 
then tied securely. 




Fig. 12. — Lane's bone plates, steel, for femur, for use in fractures 

of bone. 



41. If saline is used to mix hypos, in — i. e., cocain, 
novocain, etc. — it possesses certain advantages: 
(a) It is stimulating. 
(6) It increases the blood-pressure, 
(c) It aids absorption. 



76 



OPERATING ROOM 



42. Hypodermic needles made of platinum are ex- 
cellent. Though they cost about $2.50, it pays for the 
individual to have his own. They last forever. 

43. Be generous with finger-cots. 

44. In bone-plating, send the junior to boil everything 
each time the surgeon lays it down, before taking it on 
the sterile table again. This requires an extra assistant, 
and makes the operation long (Fig. 12). 




Fig. 13. — The Albee electro-operative bone set. 



45. Do not boil electric apparatus, especially the electro- 
operative bone transplantation instruments (Fig. 13). 



CHAPTER V 
THE HEAD NURSE 

Preparedness. — This head nurse has the work of build- 
ing forethought, honesty, accuracy, and presence of 
mind into a pupil's character more than any other super- 
visor. But these all come from preparedness. By co- 
operation with the superintendent of nurses a sane sys- 
tem of minor penalties should be enforced, since the 
responsibility of conducting a case is so great. If a nurse 
is fatigued and does sloppy work, and it is found on in- 
vestigation that she is using too many "late leaves/' 
she should be deprived, of them for a time. Not every 
pupil should get the operating-room service, because it is 
not compulsory and because dishonesty in doing simple 
ward dressings shows unfitness. If a nurse is honest and 
accurate in the details of ward work, she should be sent 
about the beginning of her second year to the operating 
room when anatomy comes on the curriculum, and before 
she begins to suffer from hospital fatigue. By getting 
this very early she can learn just as fast, and has no 
careless habits formed, while she is much more useful 
afterward on the wards in taking care of an intravenous 
infusion, blood-culture work, or phlebotomy without any 
agitation. 

The operating room thus need not be disturbed for 
any ward treatments of greater magnitude. Besides, on 
her second night duty she can assume the whole or a 
large part of the conduct of a night emergency opera- 
tion without depriving the tired day nurses of their share 
of rest. There is a general feeling that being in the 
operating room is a very honorable post, but this is not 
sufficiently utilized. The superintendent of nurses should 

77 



78 OPERATING ROOM 

warn all pupils in the early stages of their career that they 
cannot make the operating room unless they do good 
work. If a pupiPs first year work is poor, better expel 
her then than at the end of her third. It is absolutely 
criminal toward patients and unfair to a nurse to take 
three years of inferior work from her and not give her a 
diploma, while, again, giving her a diploma would make 
her the equal of good nurses in the eyes of the world. 
Considering then that a nurse is worthy to receive the 
training of the operating room, the supervisor has yet 
to show her a million new ways where she must be accu- 
rate, and many new things to resort to in new emergencies. 
Discipline. — Perhaps a little more than the ward super- 
visor should the operating-room nurse be endowed with 
power to discipline. She and her nurses are in a world 
by themselves. The superintendent might see a pupil 
do something wrong, yet she should not take that pupil 
off duty for fear of disturbing the service, nor "go in over 
the supervisor's head." In a class of 20 pupils, in a school 
of 60 nurses, only two of one class probably are in the 
operating room at one time. If they were removed, 
possibly there might be nobody or only one available to 
take their place, whereas in ward work, which is more 
flexible, less concentrated, and among conscious patients, 
a nurse of even the senior class might not be much missed. 
But the superintendent and the supervisor should confer 
frequently at the end of the day and work together. 
The pupils should be kept at a distance, though all live 
on such a close footing. There should be no familiarity 
among themselves or toward the supervisor, who does 
the directing, while they listen silently/ without chaff or 
banter. It sounds badly to a patient waiting to be anes- 
thetized. She must say the same things over and over, and 
has no time to waste in repetition for inattention or absent- 
mindedness, though she must be patient with some who are 
dull at first. They should never lose their whole "time 
off" as a penalty, but they should not get it all if they 
loaf. If they do a thing badly, as cleaning, they should 



THE HEAD NURSE 79 

lose the time thus wasted, and do it again at the sacrifice 
of a part of their "time off." Forwardness, quarrelling, 
noisiness of voice or manner, improper dress or toilet of 
the hair and person (perspiration, highly scented powders, 
and waters) should be checked at once by loss of the cap, 
degradation of position (put back from "instruments" to 
"dirty nurse," for instance), and other penalties in pro- 
portion to the offence. Ward nurses sending up a pa- 
tient improperly shaved or badly prepared so that he 
stools on the table should be reported to and severely 
punished by the superintendent of nurses. 

Teaching. — The head nurse must demonstrate all the 
work of the floor to her staff. This is severely eliminated 
by the demonstrator who teaches nursing all through the 
rest of the hospital because of the variations in technic. 
Let us hope it will soon be standardized! As the pupils 
ascend the scale — dirty nurse, anesthetic nurse, and in- 
strument nurse — they must be shown. Then they should 
do the thing, for her to criticise, without any case. Then 
they should do the thing during the operations, with her 
standing back of them and helping them. If a perfect 
rotation of pupils is executed, they pass out to do night 
duty, and obviate thus the necessity of calling her. She 
should get perfect rest. She should maintain all her vigor, 
since she is a very valuable member of the staff. Night 
work, relief work, and vacation substitution always form 
an excellent school to give the pupils self-reliance. Like 
an infant, they must be made to stand alone. Even the 
least promising do well when left to themselves, being 
quite proud and feeling untrammelled. 

When a nurse shows lack of theoretic knowledge, this 
should be reported to the teacher of those special subjects 
in which she failed, as anatomy or materia medica, and 
the points specified. Before each day's operations begin 
by a series of plates, charts, instrument catalogs, cards of 
samples, etc., she should teach the nurses their several 
duties for those cases on a very scientific basis, quizzing 
them on the anatomy of the parts and the nursing details. 



80 OPERATING ROOM 

She must demonstrate all the work of (1) scrubbing up; 
(2) the positions; (3) setting up; (4) binders; (5) opening 
all sterile goods; (6) making saline, etc.; (7) running all 
the sterilizers. 

She must pay special attention to nice points in asepsis 
and technic, so that each pupil will feel it her stern duty 
to do these things with the same meticulous care: (1) fold- 
ing linen; (2) opening a sterile towel; (3) setting up; 
(4) handing a needle-holder; (5) pouring out medications; 
(6) conducting a case. 

She must instruct the senior in the special whims or 
methods of certain surgeons, with their reasons, so that 
they will not forget. 

Details in Nursing. — Apart from the question of technic 
there is a great deal of general nursing care. A patient 
must not be poisoned with a too strong bichlorid of 
mercury solution, nor burned with iodin confined (i.e., 
running down the buttocks to the spine), nor bruised by 
somebody leaning on her, nor paralyzed by standing up- 
side down in Trendelenburg on shoulder-rests badly 
padded. The nurses should all follow up the cases in the 
wards and know how they are doing, whether they have 
primary union, whether packing is removed as specified, 
etc. The head nurse should confer frequently with the 
ward head nurses. The operating pupil bringing down a 
case should be "released" on the word of the nurse "receiv- 
ing" him that his dressings, gown, and binder are O. K. 
The position of all hypodermic injections given in the 
operating room should be charted: "Strych. sulph., gr. to, 
by hypo., in the left upper arm, half-way up, on the outer 
side, given by Margery Daw." Blame is tossed forward 
and back from one service to another, until some one thus 
stamps the blame on the real wrong doer. The nurses 
must retain their "nursing" sense, and this is helped by 
sending them to the wards on Sundays and holidays to 
relieve. The patient's modesty must be considered 
whether under an anesthetic or not. She must be draped, 
and no exposure made where unnecessary at any time. 



THE HEAD NURSE 81 

Colored physicians are not allowed to witness operations 
on any women but of their own race, as a rule, even in the 
charity wards. All tampons, packing, etc., must be 
reported to the wards. Conversation should be just as 
guarded as if the patient were listening. It is sometimes 
feared that standards are lowering. Formerly a nurse 
was completely disgraced if her patient was badly pre- 
pared. Now it is not properly reported to the super- 
intendent, and the nurse is not punished enough, if at all — 
the result is, increasing indifference. The orderly should 
not be present when women are operated on for any con- 
dition. 

Common Faults in Operating Rooms. — There should 
never be a complaint from the surgeon about the common 
subjects — (1) dulness of instruments and needles; (2) 
bad condition of the cautery or aspirating set. One 
should strive to be above all others in such things. One 
should learn from others' mistakes. One should avoid all 
the monotonous banalities of this life. 

Legal Phases. — There are many features in which a 
trusty supervisor stands as the confidential agent of a 
busy or absent-minded surgeon who has grown to lean 
on her memory and judgment. In a new position a young 
nurse should not venture to assume some of these burdens, 
but after she has "made good" it may be relegated to her. 
At any rate, this is the time to teach the pupils that a 
minor cannot be operated on without the consent of his 
parents; that a woman's generative and other organs may 
not be removed without her own and her husband's con- 
sent when found diseased upon exploration; that all cases 
must be completely recorded, for reference in possible 
future lawsuits; that the patient's interests must be pro- 
tected as well after he is anesthetized as before. A case 
is cited of a young girl undergoing the operation of ton- 
sillectomy. Another physician accompanied her, and 
after she was anesthetized he asked permission of the 
surgeon to make a gynecologic examination, upon doing 
which he made certain remarks which showed clearly that 

6 



82 OPERATING ROOM 

he had not been acting for some time as her physician, 
but merely wished to know what had transpired in the 
interval since he had had charge of her case. This need 
not have taken place at all in those surroundings. Once 
in a while when ethical courtesy is extended it is abused. 

Routine. — There are many duties to be performed. 
In some hospitals all the surgical supplies are assigned to 
this supervisor, who distributes them on Saturdays (the 
best day to avoid the old-fashioned Sunday dearth of every- 
thing) on the ward requisitions. Rounds must be made 
over the whole floor daily for general cleanliness, weekly 
for special cleaning, and at other longer intervals for keep- 
ing up the good appearance given by painting and plaster- 
ing. In the evening before going off duty it should be 
the regular duty of the supervisor to know that her staff 
is leaving its saline, infusion sets, etc., in perfect readiness 
for a night call, and that everything is done that can be 
done on that day. Let no work be carried over to another 
day. A book of house rules must be kept drawn up 
and at regular intervals revised by the Medical Board. 
There must be a general stock-taking on certain dates of — 

(1) The ward dressings and linen (of a certain uniform 
design) : 

(a) In actual use. 

(b) Sterilized reserve. 

(c) Unsterilized reserve, done up in covers, 

ready. 

(d) Fluffs, wipes, etc., made, but not put up. 

(e) Empty covers (sorted), including what is in 

the laundry. 

(2) The operating-room dressings (of different design) 
and linen: 

(a) In actual use. 

(6) Sterilized reserve. 

(c) Unsterilized reserve, put up, ready. 

(d) Fluffs, tapes, etc., sewed, but not put up. 

(e) Empty covers (sorted), including what is in 

the laundry. 



THE HEAD NURSE 83 

(3) The operating-room special goods — saline, tubing, 
pledgets, etc. 

There should be a list made up of each class, with 
a number, agreed on by the superintendent, the super- 
intendent of nurses, and the operating-room super- 
visor. She then feels free to order muslin to make 
enough covers or towels, etc., to keep up her stock. It 
allays anxiety to have a big reserve, and it does not cost 
any more once it is started. There should be a regular 
time for making saline solution, so that each pupil makes 
it so often, and it must be watched for cloudiness. But 
if there is a rush, it should be made at once, and if once 
sterilized, is good for the night at least. The nurses, 
maids, and orderly must be constantly supervised at all 
their work. By a daily slip the head nurse reports at 
the office all needed repairs and emergency supplies and 
her own "time off," since she is a very important official. 
The engineer cannot get good service out of his men if 
he does not get his requisitions early so as to assign them 
their work before 9 o'clock. A careful buyer has few 
emergency supplies to ask for. The nurses' work is com- 
pletely mapped out for the day according to the schedule 
of operations listed in the office the evening previous. 
The supervisor should work the anesthetic nurse into 
minor operations, etc., when the "scrubbed nurse" is 
"off for her time" before her term is out in the anesthetic 
room, and so on with all of them. The pupils should 
not all go newly into the three positions on the same 
date. If the wards are extravagant with gauze the 
pupils there should come up and help make dressings at 
night for an hour, to see how it feels up there from that 
standpoint. The head nurse assists in buying goods for 
her department and instructs her senior pupil at the 
same time. She knows what sick cases use up the gauze 
and cotton. She knows how much work is required in 
cutting, folding, and sterilizing, and, having it in charge, 
she is not prone to hand it out too indulgently. But she 
also knows equally well which maker's instruments last 



84 OPERATING ROOM 

well, who does the best and quickest repairs, what kind 
of goods is satisfactory to the operators, and how the 
patient fares under a cheap ether or a new-fangled anes- 
thetic. The patient first, last, and always! Any mechanic 
should have the choice of his tools, but when the super- 
intendent says, "Why won't this gauze do?" there must 
be a scientific answer. It is sleazy, not enough threads 
to the inch, or cotton may be lumpy, friable, and dirty, 
rubber malodorous, or instruments ill-fitting and badly 
plated. The supervisor must encourage the pupils to 
tell every word of approval or complaint from the sur- 
geons, investigating the latter, since she is really the 
medium between them and the office. They forget as 
they walk downstairs all the things they thought of under 
the stress of operating. It takes a "live wire" to do all 
these things to improve the surgical service and make it 
run smoothly. One nurse is appointed to care for all the 
instruments in the house; to see that ward sets are in- 
tact; to trace a missing one; to make the one who used it 
last pay for it; to list all needing repair; to check them 
off when they come back; to have some renickeled regu- 
larly; to exchange, with the supervisor's approval, poor 
ward instruments for fair duplicates, and get new for the 
operating room, subject to the instrument committee; 
to lend no apparatus without the consent of the surgeon 
on service; to get it back promptly, by frequent tele- 
phoning, from the forgetful borrower, and to give out no 
sterile dressings to any purchaser without an order from 
the office showing that he has paid for it or had it charged. 
At the end of each case the supervisor should "viser" 
each slip pinned on the chart for the ward nurse's imme- 
diate use, checking it up as to drainage, name of opera- 
tion, etc., and she personally inspects each patient's 
condition as to pulse, wrappings, binder, etc., before he 
goes down to bed. She designates which tables will be 
used for certain cases. She maintains perfect decorum 
among all her staff, so that her commands — in a low, 
clear tone — may be easily grasped. Signs, frowns, 



THE HEAD NURSE 85 

whispers are very ineffectual and confusing to a novice. 
Messages taken by a pupil outside are written, and if 
the supervisor judges them urgent are held in front of 
the surgeon's eyes. The assisting intern must receive 
messages while a case is on. Seven or eight other doctors 
and a hundred or more other patients have some claims 
on him. The head nurse also will keep an accurate ac- 
count of all narcotics, under the Harrison law, as to 
amount received and how disposed of, of stimulants, 
such as brandy (hypos.) and whisky (enemata), of de- 
natured alcohol (not designed for nurses' alcohol lamps 
nor orderlies' tippling), and of radium. 

Sterile goods must be accessible for the benefit of the 
night staff through the night supervisor only, who renders 
a strict statement of instruments, saline, or dressings 
taken. The staff must take part in all fire-drills. She 
makes rounds on the wards irregularly to see whether 
sterile goods are wasted or not. She should encourage 
each ward nurse to build up in a small locked closet a 
reserve of dressings for night or other emergencies, and 
should help to foster a cordial feeling between day and 
night staffs. It must be repeated that a large sterile 
reserve is imperative in view of — 

(1) Any epidemic among the pupils. 

(2) A breakdown of the sterilizers or steam-fittings. 

(3) A general calamity in the town — i. e., fire, accident, 
etc. 

She must direct the reading of her pupils on materials 
relating to their present work, especially of such authors 
as Dr. Brickner and Dr. Fowler. She must confer fre- 
quently with the housekeeper and the matron of the 
linen-room in regard to stains, bleaches, wear and tear, 
slow service, lost articles, patterns, materials, and suits. 
She sees that the nurses wash out all blood, feces, and 
clots before sending linen to the laundry, and that all 
iodin stains are removed first also. Use a doll's wash- 
board for small articles in a sink with a stopper, and a 



86 OPERATING ROOM 

real laundry tub for large sheets to save time in the 
model "hopper" room. This is not the orderly's work. 

It constitutes a part of a nurse's training to clean up 
everything after her case, especially unsightly blood. 
She must keep a well-bound register that will last for- 
ever, with the address of the maker and the number of 
the design pasted inside for reference in ordering again, 
and in case of fire this book should be saved. It con- 
tains a complete account of the case — patient's name, 
chart number, age, date, operator, all assistants, charge 
nurse, other nurses, operation, drainage, stimulation, 
dressings, anesthetics of various kinds, duration of each, 
anesthetist, patient's condition. She keeps also a book 
with a standard number of dressings, towels, and band- 
ages allowed each ward that it must not exceed, and in 
giving out dressings daily usually exchanges empty for 
full covers, with the understanding that the balance is 
full on the ward. A special requisition for more must 
be obtained from the superintendent of nurses, who, if 
doing her duty, knows the exact needs of each patient. 
Pupils should not run promiscuously to the operating 
room for goods. But if, outside the fixed hour, an anxious 
little head nurse presents herself apologetically she should 
not be met with a stony glare. Give her the goods and 
investigate afterward. Bad management is not a crime 
and accidents or mistakes occur. Each ward nurse should 
order ahead, and should know a day ahead when new 
drains of rubber or the "cigarette" will be needed, not 
waiting until the surgeon comes. It is much better dis- 
cipline to catch that pupil and make her do an hour's 
work on drains after she has finished on her ward. 

She should look after the health of her staff, the clean- 
liness of their hair, the style of shoes, their throats, 
and their skin. Bichlorid rashes must be avoided. If 
they occur, nightly dressings of lanolin are best. Dutch 
Cleanser and other powerful agents for chasing dirt 
must be used only while wearing coarse rubber gloves 
by some thin-skinned folk. Nurses must wash off the 



THE HEAD NURSE 87 

soap thoroughly before immersing in bichlorid, as the 
neglect of this causes a black scale and cracks. It 
is not necessary to scrub with a brush above the wrists. 
A nurse's skin is too fine. To dry the hands thoroughly 
each time they are wet and use a dash of hand lotion 
is effectual in saving the skin, and all this is for the 
general benefit. Keeping each nurse fit is advantageous 
to all. The supervisor requires alertness, suavity, self- 
control, a fine but not dominating sensitiveness, op- 
timism, power to build a well-formed schedule for each 
day, and a well-defined plan for the future. These are 
some of the salient features we so gladly find in some and 
so sadly miss in others. Upon review of all the operating- 
room supervisors one has known, how many measure up 
to these standards? We cherished resentment for the 
time that one posed to the gallery of students (only in 
their third year at that), that another spent most of her 
time talking to the interns, or that a third had no head 
for management! But a supervisor in such a strenuous 
life needs a greater amount of vacation and change of 
scene, for why should she grow gray-haired faster than 
the others on the wards? Then it is the duty of the 
Directors to pay her such a salary that she can keep her- 
self fit and retain the position long enough to work to 
their advantage. 

Ethical Relation to the House. — The operating room 
is the common stamping-ground for men who have some 
reasons, real or fancied, for jealousy. The supervisor 
can do a great deal to quell or feed this by tact or gossip, 
by hustling a little, or complaining. She must be fair 
and just to all. No one man should be allowed to begin 
a case so late that he knows it will overrun his time 
allotted. But she cannot hinder him. The hospital com- 
mittees decide that. She should report any whimsical 
technic, so that it may be regulated by the committee, 
who will back her strongly if she is honest. To be honest 
does not mean to hide things and to connive without words 
at favoring one. 



88 OPERATING ROOM 

The hospital must be humane, but it cannot under- 
take to use the time of its pupils to make dressings for 
sale or gift to any and every physician whose own family 
could easily learn. But if a doctor receives a hurry call 
while in the hospital, on the close of his morning rounds, 
when his supplies are gone, he can buy a few at what 
it costs to produce them. He should send back the 
covers promptly. If a physician presents a certain 
article to the hospital it should have no string to it. He 
should not keep borrowing it back, because had it not 
been given the hospital would have had one of its own. 
The making of saline is a delicate matter, seldom well 
done outside a hospital, but it does not undertake to 
make saline for sale or gift. People who need saline, 
dressings, etc., should come to the hospital as patients. 
However, some towns are very poorly equipped for 
contagion, and some hospitals charge tremendous prices, 
and all these questions need deliberation. The super- 
visor, therefore, must have no relations with the outside 
world professionally, except through a council of two 
people — (a) the superintendent of nurses, who should 
not lend herself to lowering the standards for caring for 
and teaching nurses; (b) the superintendent, who is sup- 
posed to know the policy of the Governors toward the 
municipality. 

Advancement. — It is hoped that the wonderful work 
of the American Hospital Association will bear as much 
fruit in efforts to standardize operating-room technic 
as it has done in other spheres. The small hospitals 
were the first to call for this because they suffer more. 
The number of whims and the kinds of goods should 
be reduced to a minimum. The greater the surgeon, the 
fewer fads and instruments. Then, if the association 
helps operating-room nurses this way, it should standardize 
their attainments by demanding some proof of their fit- 
ness. If an examination, theoretic and practical, in 
operating-room technic were held every three years, and 
each operating nurse successfully passed and had her 



THE HEAD NURSE 89 

certificate restamped, it would prove to a superintend- 
ent from whom she sought employment that she should 
make good, instead of being passed along, like a maid or 
a dressmaker, as at present, by only verbal commenda- 
tion. Each operating-room nurse should visit other 
hospitals regularly, and should arrange similar visits for 
her pupils, for comparison, instruction, and maybe, also, 
self-congratulation at times. She should at all times 
successfully demonstrate economy for the benefit of not 
only the hospital, but her pupils' future careers. Ends 
of bandages may be used for packing. Edges of gauze- 
folds will make stuffing for pads. Catgut need not be 
thrown away if the pupil is taught the anatomy of the 
part to be sutured. Stains washed out will prevent de- 
struction by strong bleaches. All the control of surgical 
goods in one hand centralizes and regulates their con- 
sumption. In a thousand ways, not by getting cheap 
materials, but by using every bit of good goods, are true 
economy exhibited and good results obtained. 



CHAPTER VI 

THE MAIN OPERATING ROOM 

This subject has been admirably handled by many 
writers, but without quoting their opinions conclusions 
similar to theirs may frequently be worked out under 
somewhat similar conditions. It would be impossible to 
graft a really ideal operating room on an old plant. A 
hospital is a growth. But even one of the points here 
mentioned may prove of value in remodelling old build- 
ings, and while all might not be possible in a new plant, 
yet they are suggested as a means of facilitating the labor 
of the surgeons and nurses, having been the result of 
years of actual work in various operating rooms (Fig. 14). 

Position. — The operating suite should be cut off from 
the busy parts of the institution and yet be within easy 
reach. No odor of ether should offend the rank and file 
of visitors. No noise of visiting, laundry or garbage 
cans should disturb the surgeons. This should be a 
"holy of holies/ ' to help clear thought, precise calcula- 
tion, and quick, clean action. The light should not be 
from the direct rays of the sun, but preferably from the 
north, in these latitudes being more equally diffused and 
casting no strong shadows. A skylight is cold and 
uncleanly, but a glass wall projecting out 2 feet to the 
north, with east and west windows and storm sashes, is 
very excellent. 

Ventilation by the direct method should be of a very 
simple, easy, yet germ-proof style, so that it may safely 
be operated by anyone, but not, however, thrown di- 
rectly on the patient. In this projection, which is ren- 
dered opaque to cause privacy and prevent nurses from 
absent-mindedly staring out, should be set separate 
panes with a swinging leaded glass, preferably up and 

90 



THE MAIN OPERATING ROOM 



91 




Fig. 14. — Model operating-room suite. 



down, in a curved box following the path of the pane, the 
floor of this box being fitted with the finest wire netting. 
Frosted glass causes an equal diffusion of light. 



92 OPERATING ROOM 

Temperature. — The engineering department should 
be equipped to send forced drafts in summer of cool 
washed air, but unsteamed, from the sterilizing room, and 
in winter of warm washed but unsteamed air into the 
central room where the wounds are made. Hot- water 
heating (75° to 80° F.) is also quite favorably considered, 
in which case the radiators should be composed of coils 
so spaced as to permit easy daily cleaning, since cold air 
carries to them the dust which their heat redistributes. 
If on the floor radiators should be covered with white 
boxed muslin covers, laundered daily, to prevent that 
fan-shaped distribution of dust that clouds the walls, 
to say nothing of the vital statistics. There are modern 
hot-water coils built up the wall which largely obviate 
the dust trouble, since the coldest water is at the bottom. 
For the patient's sake the heat should be quite uniform 
when he passes from one room to another, especially 
going back to bed, since ether opens every pore. This 
uniformity of temperature is more likely to be wholesome 
for the nurses also, who perspire freely during operations. 
During the progress of a case the patient is quite scantily 
clad. Limbs suspended in mid air a long time grow very 
cold even in a warm room. Trendelenburg always gives 
cold feet. The staff, therefore, should dress lightly to 
endure the temperature which the patient needs. Com- 
mon sense is necessary in judging what is suitable for 
nurses, the supervisor setting them an example in modesty 
and becomingness regarding caps, collars, neck-bands, 
sleeves, shoes, etc. There should be no decollete effects. 
Outside the actual operating room the full uniform 
should be worn, i. e., the moment a case is finished the 
nurses should take off cap and gown to clean up. Special 
gowns of light muslin or Indian head and caps of sheer 
lawn are devised for this purpose, and should be plentifully 
provided in all sizes and lengths. 

It is positive cruelty as well as waste of effort to make 
human beings work in steam-laden air. Steam causes 
undue perspiration and loss of energy, spoils the instru- 



THE MAIN OPERATING HOOM 93 

ments standing in closed cases, and chips off paint. The 
sterilizing room should be cut off at its entrance from the 
rest of the suite by an open-air corridor or shaft from some 
roof-garden or balcony above and below. The pipes 
from the sterilizing room, running into the operating 
room from the sides, are not affected by this. It will 
take the fertile ingenuity of a modern architect to solve 
the problem of this open-air shaft, but it must be done. 
A skylight in the sterilizing room partly obviates the 
difficulty. The steam vents should be connected with 
the open air, but visible through glass. Until these two 
features — of an open-air shaft outside the entrance to the 
sterilizing room and hoods connected with the outer 
atmosphere over the steam vents — are worked out there 
will be a constant drain of energy for nothing. The 
steaming or boiling-up of instrument and utensil steril- 
izers, and the opening of certain windows to confine this 
steam where it belongs or to chase it outdoors, must in 
any case be carefully attended to by a thoughtful super- 
visor. It is not sane to confront a highly skilled profes- 
sional man like a surgeon with the same disagreeable 
conditions that form the subject of eager charitable public 
investigation in factories, when he saves lives and the 
factories simply make paper or cloth. When a life is at 
stake, for one crucial space of time, everything preserving 
vigor and presence of mind is an asset for the whole 
municipality. 

Corners. — Coved corners are best for ceiling and 
floor. To free the room from germs the best method is 
to turn on live steam for an hour by special pipes and 
other fixtures from the boiler-room, adjusted outside the 
operating-room door. 

Fumigation is declared out of date, but if still resorted 
to requires special attention to these points: 

(1) Leave one window unsealed, but closed. 

(2) Put a damp towel over the face when entering to 
open up. 



94 OPERATING ROOM 

(3) Formaldehyd is a germicide (KMn0 4 §iv to forma- 
lin Oj to every 1000 cubic feet of air space). 

(4) Sulphur is an insecticide only. 

(5) Seal up all apertures connecting with hot-air shafts, 
etc. 

(6) Protect the floor from stains by the overflow in the 
chemical reaction of the permanganate. 

(7) Leave nothing inside that can be boiled or steam- 
sterilized, in case it may be. needed. 

(8) Have some place else to work in if this room is 
closed. 

Any day a case may be operated on that shows ty- 
phoid bacilli, tuberculosis, or some of the exanthemata, 
and it is an important asset to be able to disinfect the 
whole room quickly and easily. In its broadest sense, 
the "operating room is never out of commission." Some 
special instrument might be needed the moment the 
live steam was turned on, and the impossibility of getting 
it might seriously delay another case. The operating 
room is in no sense a store-room, and it is not the cleanest 
room in the house, since purulent cases are opened up 
there, and people come off the street to view opera- 
tions. There should always be a simple plain store- 
or stock-room nearby, well cared for, to work in for a 
day. 

The instrument cases should be kept outside the 
operating room, with labels, tags, names, and numbers 
according to the kind of goods, the surgeon who owns 
them, their sizes, and other individual traits, so that they 
may be found in haste. An instrument should have a 
uniform name according to its purpose. On each shelf 
should lie a list of all the instruments on it. 

We must distinguish between the sterilizers that are 
run for the whole house and those run for the immediate 
benefit of the patient on the table. For an operation 
everything needed in it should be as close as possible, 
and other things quite far away. 



THE MAIN OPERATING ROOM 95 

It is not advisable always for the supervisor to scrub. 
Careful drill on her part, talks in anatomy, lessons on 
sutures, a quiz before each case, and a graduated sequence 
of duties will fit her nurses to pass instruments. The 
most skilful nurse should be least hampered. Some 
women who are paid to supervise love to get into a sterile 
gown, intrenched behind which they give frowning orders 
that confound and perplex the pupil, making her resent- 
ful and conscious. If the surgeons do their share cheer- 
fully in training the pupils, and show self-control, not 
anxiety, when a new pupil reaches the instrument table, 
they will be rewarded by enthusiastic devotion. All 
the arrangements of the operating room form the keys 
and stops of a big organ, and the best skilled player is 
the supervisor, but she cannot play a fugue by choosing 
only to work the bellows. She should be free to super- 
vise a second case in another room, or in many rooms, 
according to the size of the institution. 

Many small hospitals feel that they cannot afford a 
second small operating room for pus cases. This mooted 
question brings up the difficulty of diagnosing the pres- 
ence of pus. In any case, a "septic" operating room 
should be steam-sterilized every time it is used, and left 
aseptic. 

Dark Room. — Again, for all the "scopic" work, whether 
it be cystoscopic, laryngoscopic, or, again, submucous 
operating, the dark-room is necessary. Any room 
should be easily converted into a dark room, but it should 
not be one that might be needed simultaneously for 
another purpose. If the Medical Board would assume 
its responsibility this could be decided by the amount of 
work done by the man desiring the "dark room." If 
his cases are very few, they could be done at night in the 
main room. It makes for uncleanliness to- have roller 
shades in the main room. Frosted glass only is desirable 
by day. But a fair way to settle all questions of privilege 
and necessity is not by a hole-and-corner caucus of a few, 
but by open discussion between the two Boards. 



96 OPERATING ROOM 

Plumbing. — The scrub-up stands should be in the 
main room, but not used for any but the case in progress. 
Plumbing for these is a vexed question. The knee-swell 
is an excellent thing in theory, but its parts have not 
been made strong enough throughout to bear the strength 
necessary to open the valves. The foot-tread has worked 
out best in most cases. There should be only one faucet 
containing mixed hot and cold water, and no stoppers in 
the bottom, since the hands must not touch any but 
fresh-flowing water. It is imperative to have an easy 
but always reliable adjustment of the temperature of the 
water, since frozen or scalded fingers are more susceptible 
to bichlorid-poisoning and less capable of palpating or 
holding delicate structures. The soap should drop from 
jars above the basin by means of a push with the elbow. 
The nurse cleaning this room in the morning should, 
therefore, be responsible for this plumbing. If it is not 
in order, she should move heaven and earth to get it in 
order in time for her case. When repairs are in progress 
anywhere in the hospital the arrangements should not 
interfere with the operating room, if avoidable; but if 
the hot or cold water must be cut off, the head nurse 
should stipulate, as her duty to her cases, at what hours 
it may best be done per schedule for the day. In cases 
of accident some one should hasten to turn the taps in the 
largest tanks before it is cut off entirely. When the 
engineer turns it on again after the repairs the inevitable 
sediment should not be allowed to flow over linen or deli- 
cate instruments. 

Faucets are installed in the main room running from 
the sterilizers, and these are cleansed with disinfectants 
at the mouth every morning. They are controlled by 
foot-treads or knee-swells, but the orderly will have 
polished them. They supply the basins for rinsing 
gloved hands, for washing instruments during cases, the 
irrigating tank, etc. Faucets for ordinary hot and cold 
unsterilized water are also needed for the scrub-up 
stands. 



THE MAIN OPERATING ROOM 97 

The table and cabinets should be made of nicalloy. 
It is substantial, durable, and handsome, besides being 
easily cleaned. To establish the system of anesthetizing 
the patient on the table and wheeling him in (to save 
lifting and bruises) such a table should have a very broad 
pedestal or four legs, with solid, low, broad casters. This 
table should be selected by the surgeons of the staff in 
committee, each trying to dispense with instead of demand 
a number of unnecessary fixtures. All handles and levers 
for Trendelenburg should be controlled by the anes- 
thetist, who is responsible for the patient's life. He 
must act quickly. The old-fashioned table can be raised 
for a tall surgeon by setting it in four equal lengths of 
stout gas-pipe, . a solid bar inside each leg, running up 
into it and down into the gas-pipe. 

There should be stools of graded heights, shapes, and 
lengths for the assistants at a case requiring Trendelen- 
burg, and as seats for the anesthetists or nurses. It 
should be an understood thing that a nurse might be 
seated for a few moments rather than stand to the point 
of exhaustion. Her internal mechanism demands it. 
She is on duty in the operating room all day. The sur- 
geon does one case or so and departs. A few moments 
in a different posture plus the knowledge that one has 
that privilege help drive away fatigue. 

Electricity is used in many forms. The engineer is 
called upon to demonstrate and teach the meaning of 
the following: (a) Direct current vs. alternating current; 
(b) transformer; (c) rheostat; (d) switch; (e) watt; (/) 
cystoscope, etc.; (g) battery; (h) dry cells; (i) storage; 
(j) fuse; (k) motor; (I) dynamo; (m) cautery. 

Every common fact about electricity must be known, 
so that the pupils may handle an auriscope or a cautery 
without damaging it. Bulbs should not be screwed in 
and out when the current is on, for fear of blowing out 
the fuse and putting out the lights on one line. There 
should be chains on each separate high light, so as to 
enable a short nurse to turn off all but one. When con- 



98 OPERATING ROOM 

necting up an electric instrument the light should be 
tested, then turned off, until the adjustment is made. 

Electric light is used in many forms. By day in a 
dull climate electric reflectors are used, and possess many 
advantages if sufficiently high to be diffused, especially 
in old institutions. For a small operating room in an 
ordinary town service six powerful 100-watt Tungstens 
make an excellent night light. They should be up too 
high to burn a tall surgeon's head. A ground-glass plate 
is slung beneath them, as long and wide as the whole 
chandelier, making no strong shadows and preventing 
dust or burns. Again, the whole ceiling is sometimes of 
ground glass with electric lights above it in an arched or 
angled attic, where, of course, only the electrician can 
repair and exchange bulbs and fixtures. Still better is 
the wonderful Zeiss light which is generated outside the 
operating room, and is thrown in upon a large number of 
mirrors, whence it falls in six or more intensively illumi- 
nating direct pencils upon the wound. These pencils of 
light do not cast a shadow if a person intercepts them. 
The outfit is expensive and at present impossible to ob- 
tain. Frosted or ground-glass bulbs are necessary for 
eye work. Every sort of droplight, to be held by hand or 
on a flexible metal coil, should be provided and wound 
with sterile gauze. Patients under anesthesia are easily 
burned by lights if held too near or left lying on them. 
The "rolling stock" of casters and rollers should be so 
arranged that while one part is away for repairs, there 
is a good duplicate in its place. If the surgeon wishes 
the table immobilized the casters may be removed. 
Lock rollers are a good device for this purpose. 

A silent clock, which simply throws out a sheet an- 
nouncing the hour and minute in big black letters, is a 
very pleasing feature, as used by the M. E. Hospital in 
Brooklyn. 

Instrument and sponge tables should have only one 
shelf, so as to save the nurse her clumsy efforts to be 
aseptic by stooping, winding the table in bichlorid towels, 



IH?; MAIN OPERATING ROOM 99 

and struggling with shelf covers always quite too large or 
too small. Everything to be used for the patient should 
be on a level with his body as he lies flat on the table. 
You know about how long floppy, sloppy sheets remain 
"sterile" below the level of one's knee. Operating has 
been so speeded up and simplified of late that fewer mate- 
rials are required. Result, the scrubbed nurse has fewer 
"impedimenta." 

In a private house the hostess has at her foot, under 
the dining-room table, an electric push-button to sum- 
mon the maid. Similar bells ought to be provided for 
the scrubbed nurse. If the unscrubbed nurse goes out to 
boil up an instrument she need not stay with it. She 
may be thus summoned. It is an agonizing and monoto- 
nous feature of breaking in new nurses to teach them, how 
to know where to be. 

Special Table Pads. — On the stretchers and table 
should be stout pads of curled hair specially bought for 
the purpose, instead of folded blankets renewed so seldom 
as to be thin and hard, the mother of a hundred bed- 
sores, especially on a sick, emaciated patient hanging by 
the coccyx in a lithotomy position for one-half hour or 
more. 

Tonsil Table. — Throat cases, when this branch of the 
service is heavy, should have a special table on which 
they may be slowly lifted to the sitting posture while 
under the anesthetic. The heart is overdriven by ether 
and weakened by chloroform, so the patient must be 
very cautiously raised, by the anesthetist only, to the opera- 
tor's fancy. To prevent slipping, a seat of corrugated 
rubber matting is provided. 

Cautery. — The fixtures for the cautery should be in the 
main room, at a proper angle, out of the way of the opera- 
tor. There should be a low truck of heavy pine built, 
with a cover and solid casters, to move this heavy ap- 
paratus for cleaning, dusting, and cauterizing purposes. 

Evacuating Cysts. — Provision must be made for re- 
moving in a cleanly manner the contents of large cysts or 



100 



OPERATING ROOM 



purulent exudates. The operating room can be equipped 
with a large aspirating set, capable of drawing off several 
gallons of cystic fluid, if planned from the engineering 
department in the beginning. The smallest size of "H. D. 



To JZ/'schary 



•sreasn yo/*& 




3 llip 






Wafer or 
J? /s /'/? fs c tanf 



Fig. 15. — An H. D. ejector. 



ejector" does the work most efficiently (Fig. 15). It is 
connected with high-pressure steam from the boiler-room 
and discharges to the atmosphere, i. e., the outside air. 
To the suction opening of the ejector (i. e., the wall of the 



THE MAIN OPERATING ROOM 101 

operating room) is connected a rubber tube leading to a 
bottle partly filled with water. From this bottle another 
tube goes to the patient (injection of aspirating needle). 
The fluid is started off by opening the valve at the wall. 
The fluid drawn passes into the water in the bottle, where 
it remains, while any air that may be drawn in at the 
same time passes on through the ejector to the atmosphere. 
When the air is all expelled the cystic fluid follows it to 
the atmosphere (i. e., outside the building). 

If a radium outfit is owned by the hospital it should 
be kept under lock and key, being very costly. Its 
powers are measured as "emanations" in units, called 
"mache units," so many thousand per minute. 

Doors. — It is not good technic for the surgeon or nurse 
to pass through doors after scrubbing up, therefore there 
should be a row of four stands in the operating room. 
Five persons may be needed, but the two nurses need 
not scrub when the doctors do for two successive cases. 
In the first case they scrub first. Doors should be pro- 
vided with the best of springs, set in boxes in the floor, to 
fly both ways, each having a window of wired glass, about 
1 foot long and 2 feet wide, set in the bottom of the upper 
third of the door, flush with the wood, so as to distinguish 
the presence of anyone on the opposite side. This pre- 
vents costly head-on collisions, and should be uniform 
throughout the house, where swing-doors are needed, in 
pantries and lavatories. 

Waste receptacles for empty covers or for the gory 
towels of a tonsil case, if they must be in the room, are 
metal frames on casters, with a bag of white duck or can- 
vas inside, freshly laundered and changed for every case. 

The irrigating tank should always be well oiled and dust- 
less. 

Other Rooms. — When a small hospital is being built on 
a limited scale its fixtures should allow of alteration — e. g., 
from steam- to hot-water heating or from gas to electricity 
— but the Governors should plan to improve; to hitch 
their wagon to a star. Some companies have a draught- 



102 OPERATING ROOM 

ing department where the men must be kept busy, there- 
fore for a small sum they draught and make blue-prints 
of operating-room suites according to the amount of 
money that the Board has to spend. 

Off the main room, by communicating corridors, 
should be found — 

Instrument cabinets. 

Anesthetic room. 

Store-rooms, for raw goods, sterilized goods, and 
dressings in wrappers. 

Workroom. 

Hopper room. 

Sterilizing room. 

Doctor's dressing-room, with showers, toilets, and 
lockers. 

Nurses' Dressing-room, with shower and toilets. 
This much is imperative. There may be, besides, 
"dark" and "septic" operating rooms, others for special 
work, as gynecology, or for some particular surgeon. 
There should be free currents of air and powerful light in 
all, and not any germ-laden holes under amphitheaters 
where these two disinfecting agents cannot penetrate. 
Where is the hospital that has provided decent conditions 
under which all of its nurses can work? 

Preferably, the color of the walls is soft dull green with 
an unglossed finish so as to cast no high lights. Some 
operators prefer a lusterless pearl gray, but it is generally 
conceded that green is more restful. There must not be a 
sharp contrast between a wound, with its red blood, 
brown-gloved fingers, and white gauze, and the wall 
above, to which the surgeon lifts his eyes when concen- 
trating his attention on what he is palpating. 

Elevators. — It is very essential to be near the elevators 
and to have absolute control of that service. Everything 
stops when a patient is to be taken up or down except 
the services being rendered him. For fire-drill the ele- 
vator should go to the operating-room floor and stay 
there. In the equipment for fighting fire the operating- 



THE MAIN OPERATING ROOM 103 

room floor requires extinguishers and hand-stretchers 
just like other wings or floors, especially because the pa- 
tient is unconscious. Drill should consist of turning 
down the hand grenades, carrying a patient down the 
stairs (if the elevator shaft were in flames), closing all doors 
and windows to prevent draughts, making an exit down the 
fire escape which must be provided for this suite, providing 
wet masks and blankets for all, manipulating the wheeled 
stretchers as necessary, and definitely appointing each 
his station. 



CHAPTER VII 

THE STERILIZING ROOM 

The sterilizing room should be considered under the 
head of the operating-room suite, though in some very 
large purely surgical institutions it is conducted separately 
by a graduate nurse on account of the extensive, accurate 
work involved, though the obligations incurred have to 
be rendered^ to such an immediate neighbor that friction 
may occur where mistakes are made in the former. The 
sterilizing room should be cut off from the rest of the suite 
by a shaft of open air, especially easy when there is a 
loggia or balcony below and nothing above but roof or 
another loggia. The cold air coming up the shaft causes 
a condensation of vapor which otherwise would raise the 
temperature of the rooms and depress the vitality of the 
workers. Besides, cutting down this vapor saves the 
walls of the suite enormously from chipping of paint, 
falling plaster, etc. Cooled air can be forced up a flue 
from the engineering department, pushing out the vapor- 
laden atmosphere, while the air-shaft, lying between 
two solid walls and connected with the rest of the suite 
by stout swing-doors, need not be so wide that a nurse 
could grow chilled passing through. If it is bounded on 
the top by the sky it should be protected from rain and 
snow. The gangway should have high balustrades. 

The sterilizers for water should both contain a cold coil, 
so that, no matter which one is the hotter or the lower, it 
can be cooled and used in emergency. Where this has 
been installed the supervisor states emphatically that it 
saves both time and anxiety. Each has two taps, one 
on a pipe into the operating room. 

The sterilizers must be run every day, no matter whether 
there is operating or not. They should be large enough to 

104 



THE STERILIZING ROOM 105 

furnish water for twenty-four hours of steady operating 
— imagining a frightful contingency, such as a railroad 
wreck. There should be no extravagance, but there 
should always be a liberal supply of all those materials 
that it is impossible to prepare in a moment — cold sterile 
water, towels, gowns, and dressings. In small hospitals 
the steam is generated by gas, but these fixtures should 
be put in so as to be interchangeable with steam. Damp 
dressings are not sterile. 

Nickel is the best-looking material, cleaned when 
cool with any good nickel polish. The suffocating smell 
from brass polish makes other metals undesirable. The 
taps from the sterilizers into the operating room, as 
well as those in the inner room, should be cleansed with 
green soap and a brush, then alcohol, then rinsed after the 
orderly polishes them. The body of the sterilizer may be 
set quite high, in order to obtain pressure on the operating- 
room side at delivery. It is a sterile receptacle which is 
brought to them always to be filled, and should be covered 
with a sterile towel if sent to the wards. Even though we 
know it is filtered and boiled, it must be observed as to 
color, cleanliness, etc., daily. 

Filters. — There should be two filters for each set of 
sterilizers, one in use and one being cleansed and aired. 
Each nurse must learn how to run all of the sterilizers, 
since she has to do that work, not the orderly. A nurse 
should not pass up the care of this part of the equipment, 
since it demands a conscience and causes no fatigue. It 
requires some of the qualities of honesty and reliability 
that her diploma stands for. 

Sterilizers are best placed on a solid pedestal with 
exposed fixtures and in the center of the room, not 
close to a wall. It is much easier to repair them. The 
utensil sterilizer should stand very low, so as to have 
no strain on a nurse's arm when she lifts out basins. 
Much more important is the height of the instru- 
ment boiler, which throws live steam in the face in 
most cases. 



106 OPERATING ROOM 

Engineer's Instructions. — The engineer's services are 
required in instructing pupils in the mysteries of water 
and steam, showing them the make-up of a valve, a 
water-jacket, a coil, a hydraulic lift. In their minds 
should be firmly fixed a diagram of the journey made by 
the steam so as to prevent future explosions, wet dressings, 
etc. One valve cannot be opened without affecting the 
whole system, and to open a series of valves in the wrong 
order may wreck the whole equipment. 

A certain specialist in sterilization has declared that 
the live steam should circulate directly through the 
chamber of the dressing sterilizers all the time, and he 
has had the autoclave altered by the addition of a small 
vent at the front on the lower edge with a stop-cock. 
When the gauze shows 15 pounds' pressure, the stop-cock 
is opened so as to allow a tiny stream of live steam to escape 
with a shrill, whistling sound. This must be continuous 
during the half-hour. Besides, the theory is advanced 
that sterilization of a test-tube with only one open end 
is imperfect, and that the live steam must pass through 
them, with the result that all gauze packing is done up 
in glass cylinders with two open ends. There should be 
two dressing sterilizers at least, so that if one is out of 
order or if there is a heavy rush of work there need be no 
loss of time. Formerly drums for autoclaves were made 
so large that the nurses handling them were nearly killed, 
especially as orderlies are very ubiquitous. The small 
long autoclave, with drums about 16 inches in diameter, 
is found to be a great improvement. The round dressing 
sterilizer is best for holding flasks of saline. In packing 
drums what is needed first is put in last. The nurse 
packing it then drops in a slip bearing her own signature, 
so that if it holds any errors she will be reprimanded 
directly. This positively reduces the number of errors 
in packing. A drum is packed with the goods neces- 
sary for a certain kind of case, but, of course, the main 
supply of sterile dressings is also drawn on. If drums 
containing sterile goods stood idle a much larger outlay of 



THE STERILIZING ROOM 107 

linen would be required. A specially designed low truck 
is used to draw the drums into the operating room. 

In a busy time, in order to let the day nurses off earlier, 
the night staff should run the sterilizers, either before the 
patients go to sleep or after they waken. The fact results 
in the condition of having only the roof above that few if 
any could hear this. When the sterilizing room is walled 
off by an open-air shaft it may be operated during cases 
without disturbing the surgeons. 

Tests for Complete Sterilization. — Several tests for per- 
fect sterilization are to be had. There is a small tube 
which opens only when the right degree of heat is at- 
tained, and which is wrapped in a double muslin cover 
in the center of all the bundles or in the heart of the 
middle drum. When they are kept at 15 pounds for one- 
half hour and opened up, the fact of this tiny test-tube 
being open is proof that the sterilization was correctly 
done. Other tests are made with actual bacteria from 
cultures or smears. All gauze and cotton should be put 
up in double covers of stout muslin and used in the order 
of date of sterilizing. Fractional sterilization means for 
three days in succession, one-half hour at a time, to kill 
the spores. Tubes are closed with plugs of gauze and 
cotton, then wrapped in double muslin covers. This 
responds to the most accurate bacteriologic tests. Iodo- 
form must be used occasionally and is sterilized in brown 
jars or brown glass tubes. To have covers plenty large 
enough to tuck in tightly (placing the contents diagonally) 
will dispense with a great deal of soreness in fingers useful 
for better purposes. A tailor's thimble with the end 
open helps in putting in pins. Filter-paper should be 
sterilized before making saline. 

Distillation. — The sterilizing room is the proper place 
for distillation. The little plant for this can be installed 
near the corner with two faucets, one for the inner room 
and one for the operating room, the latter pipe running 
through the wall or isolated on the deal counter in the 
middle of the room. Distillation is imperative for cer- 



108 OPERATING ROOM 

tain uses in every department of the hospital. A small 
outfit, kept going steadily, produces enough at a very 
slight cost. Under certain climatic and topographic con- 
ditions even distilled water will make a cloudy saline 
solution, which, however, disappears usually on the ap- 
plication of heat. Distilled water should be drawn off 
into sterile containers and sterilized again, like saline, 
before using, since what is on the inside surface of the 
container itself may develop life, with the aid of the 
water, otherwise. 

This room, which ought in one sense to be the cleanest 
of the whole suite, where utensils, linen dressings, and 
instruments are made ready to approach a wound, is not 
a proper place to scrub up in or to wash out bloody linen 
or pus. The former should be done by the nurse in the 
main room. The latter should be done in the hopper 
room; also the cleaning of instruments. On account of 
this room being cut off by a cold-air shaft nothing but 
sterilization should be done there in justice to the 
nurses. 

This room needs a large clock, kept in perfect condition, 
to time the water and dressings by the code drawn up by 
the house pathologist and O. K.'d by the surgeons. To 
a busy nurse, alone in an outer room, an alarm clock set to 
go off at certain times is a priceless boon. 

The utensil and instrument sterilizers should both be 
operated by a hydraulic lift, and a special pair of clamps, 
kept cleanly boiled, in the end of the latter to move the 
basins in the former, which are put in face down, so that 
they could be lifted out by hand if necessary. 

A glove sterilizer where all the gloves are boiled separate 
from sharp-pointed instruments is a great luxury. This 
should be lined with a muslin bag to prevent the gloves 
from touching the metal. A thin layer of white muslin 
in any boiler aids one in counting all the instruments. 
The glove rack, like a hat-tree, thickly studded with 
finger-shaped prongs, a glove to a prong, stands here. 
The gloves must not be laid on a radiator. 



THE STERILIZING ROOM 109 

Printed Instructions. — There should be printed codes 
of instructions on the following: 

(1) At what regular dates to have all the equipment 
inspected by the manufactured agent and overhauled, 
with their address, for the purpose of getting emergency 
repairs quickly. 

(2) Directions how to act in emergencies; e. g., flooding 
of the utensil sterilizers, leaks, etc. 

(3) Directions how to run each and every piece. 
There should always be at least two persons on duty 

who understand the running of this apparatus. But 
printed rules are of no use until the supervisor has de- 
monstrated every feature to her scholar and has seen the 
scholar do the same thing correctly and often enough to 
be automatic. It is wise in buying to secure a guarantee 
for all repairs for as many years as possible. 

Infections Due to This Department. — Not all infec- 
tions are traceable to the sterilizing room, if indeed, any 
are. But if a hernia becomes infected, which is a great 
disgrace, every means must be employed to ferret out the 
cause. The surgeon and the pathologist work here hand- 
in-hand, co-operating with the supervisor. Every avenue 
is opened to investigation. There is generally one definite 
cause and that not far to seek. If a series of infections 
occur, every gown and glove should be marked, traced, 
and set aside, as well as dressing-covers, basins, etc. 
The surgeon should relate the nature of all the cases he 
has handled elsewhere. Cultures taken on all hands, 
examination of new catgut, complete quarantine of dirty 
cases on the wards, cultures of the infected wound, ex- 
amination of throats and nasal passages, a general wash- 
ing of heads, etc., will lead to ultimate discovery and pre- 
vention. When cleaning up after a dirty case the nurse 
should scrape her short finger-nails across a cake of soap 
first. 

Safety Devices. — The less complex the equipment, the 
more nearly certain the supervisor can be that her pupils 
are manipulating it properly when her back is turned. 



110 OPERATING ROOM 

All apparatus should have safety devices to prevent ex- 
plosions. All the sterilizers should be controlled entirely 
by a lever in front. All steam fittings and plumbing 
should be quite far out from the wall to permit perfect 
polishing, dusting, painting, and repairs. 

The blanket warmer stands in the sterilizing room, 
being heated by steam in a jacket. When a nurse goes 
for a blanket she should take one to leave in place of it, 
and a Turkish towel to wrap around the hot one. 

Electricity for sterilizing is neat, but a cause of forget- 
fulness and destruction, therefore not to be recom- 
mended. Nurses have much on their minds and should 
not have to face this extra care. 

Flooring. — On account of the immense amount of 
plumbing and the condensation of vapor the floor becomes 
very slippery, and a nurse in a hurry may sustain a bad 
fall. The lower floor should be impervious to moisture, 
but it may be laid suitably with strips of cork or corru- 
gated rubber matting. "Safety first," 



CHAPTER VIII 

THE WORKROOMS 

The room in which dressings, plaster bandages, and all 
packages are made should be large, light, and airy to 
preserve the nurses' health and produce well-clone tasks. 
Each nurse — head, scrubbed, anesthetic, and junior — 
should have her fixed place to work at, but if there are 
fewer nurses each kind of work should have its place and 
the nurse should go to it when ready. The windows 
should be of a very flexible adjustment, to admit air in 
large or small quantities without draughts. Along the 
inner wall there should be numerous cupboards to keep 
the goods in process of making only, as distinguished 
from the goods in bulk and those in covers or sterilized in 
reserve. The head nurse should have a .solid well-built 
desk, with locked drawers, for the operating register, 
nurses' record cards, and similar data not to be handled 
by others. Here she can write out her records when the 
day is done. An electric desk lamp should be provided 
for night work. A spindle occupies a prominent place 
here, holding all the memoranda of the staff, and cleaned 
off daily. In the center of the room stands a long, low 
deal counter, always spotlessly clean, with stools or 
heavy solid kitchen chairs of assorted heights (from the 
floor), so arranged that the knees ma}^ go under the 
counter and the feet find rest on a bar down the center 
at the floor. Of all the work in the hospital the least 
provision has ever been made for what goes on behind 
the scenes in an operating room. Footstools and step- 
ladders are to be provided to reach the top shelves of cup- 
boards, all of the latter bearing lists on the doors showing 
what they must contain. Stools should have holes in the 

in 



112 OPERATING ROOM 

seat to lift them by, and, like the aseptic operating-room 
furniture, all should have rubber feet. A sewing-machine 
kept in good condition should stand with its left-hand end 
at a window, and not far away an ironing board and an 
electric iron, none of these to be used for the nurses' 
personal benefit, of course, but for covers and other special 
articles. Work cannot be efficient if done on the corner 
of a crowded table or put away helter skelter in one com- 
mon cupboard. 

(1) Do all one kind of work at one time. 

(2) Have a place for everything and always restore it 
immediately to its place. Do not wait one moment. 

(3) Clean everything away at night in such a manner 
that it can be resumed at once in the morning. 

(4) Avoid continued conversation and do not become 
familiar and overfriendfy. 

(5) Do not make the workroom a scene of visiting by 
convalescents, friends, or physicians. 

(6) Dust the workroom morning and evenings on ac- 
count of the fluffy dust off all goods. 

(7) Mark off the deal table in yards, halves, and 
quarters at each nurse's station, and out in front of 
her the various sizes of compresses, sponges, etc., in 
squares. 

(8) Keep here various sets of labels and nurses' signa- 
tures to put on or drop into special packages, i. e., infu- 
sion sets, drums, etc. 

(9) Allow no loafing, but arrange that those fatigued by 
standing may rest, sitting with their feet off the floor. 

(10) Preserve all introductory steps toward asepsis in 
the workroom, frequent washing of the hands, etc. 

(11) For making special dressings — i. e., boroglycerite 
tampons, iodoform gauze, etc. — -use a thick glass slab on 
the deal work table. 

(12) The floor should be of narrow hard-wood strips, 
w T hich have more resilience than tiling. This applies to 
the store-rooms, dressing-rooms, etc., but not to the 
main operating room or sterilizing room, of course. 



THE WORKROOMS 113 

(13) Keep plenty of light supplied on dull days when 
work of a fine, close, or arduous nature is in progress, 
but fine the person a penny who leaves a light on when it 
is not in use, and devote the proceeds toward the purchase 
of some luxury. 

(14) A set of teacups and a tea urn or coffee percolator 
make largely for content and good work so long as these 
tired nurses honorably avoid taking advantage of the 
privilege, and do not keep their one single luxury too 
much in evidence, especially when a patient is about to 
be anesthetized. 

(15) The nurses should call one another by the same 
titles used in class, "Miss A., Miss B., etc., etc." 

(16) There should always be some nurse on duty and 
so stationed that she may see visitors, answer queries, 
and present a neat appearance. While there is linen to 
wash out, etc., there should be no fewer than two on 
duty. 

Hopper Room. — The hopper room should contain a 
high sink, several hoppers, and a set of tubs for rubbing 
out blood, feces or stains, and for disinfecting. When 
the tubs have plugs at the bottom it is not necessary to 
to have plugs in the hoppers. But in all fine drains are 
necessary to prevent the passage of cotton into the 
plumbing system. The hopper room should be con- 
stantly aired. Arrangements are necessary to notify the 
laundry when wet linen is sent down, so that it may be 
soaked again immediately, therefore a loud electric bell 
at the foot of the chute is wired to the operating-room 
floor for that purpose. The chute opens in the hopper 
room, and the button beside it is not rung for dry wash. 
One wall is lined with cupboards for mops, floor brushes, 
dusting-cloths, basins, etc., all of which are washed, 
boiled, or sunned before being put slwslj. A set of three 
rings attached to screws arranged vertically on the walls 
makes an excellent broom or mop-holder. The cupboards 
should have only wire-screen doors in order to maintain 
a good airing system. 

8 



CHAPTER IX 

ASEPSIS 

Asepsis means the absence of pathogenic micro- 
organisms; in other words, freedom from dangerous 
germs. 

Methods of Carrying Out Asepsis. — In the nurses' text- 
books on bacteriology is given a history of all the efforts 
of modern times to reduce operative surgery to a harm- 
less process by excluding all dangerous germs from the 
field. Results are now almost as good as one can hope 
for, but, while scientists have almost reached their goal, 
the nurse must daily make the same tremendous effort and 
maintain the same ceaseless vigilance in running steriliz- 
ers or boiling instruments; in unfolding sterile goods or 
"setting up" for operation. Everything must be done 
"with a conscience." In past times when a superin- 
tendent wished to let a nurse down easy who was old or 
homely or hateful she generally described her as "con- 
scientious," but nobody can really tell whether a nurse is 
conscientious or not without observing her every day, 
unless perhaps it be a very intelligent patient or the other 
nurse whose work dovetails into hers. The foundations 
of asepsis are "conscience" and intelligence. A head 
nurse must early drill her pupil into good habits of body, 
just like calisthenics, so as not to bump into sterile 
tables, until she can move about the operating room with 
ease and safety. A pupil should on this service act as if 
she had a set of delicate antennae all over her person, 
warning her when she approaches "red-hot" — i. e., sterile 
— goods. She must think with her elbows, the corners of 
her apron, or the peak of her cap, knowing how wide a 
margin of safety they require to keep away from sterile 
things in every direction — above, below, or at the side. 

114 



ASEPSIS 115 

Then, too, in regard to boiling instruments or running 
the sterilizer, a head nurse cannot leave the ordinary un- 
mechanical minded pupil alone with such complicated 
apparatus until she has absolutely mastered it, even after 
which she should quietly take note of the steps employed 
by the pupil to time herself in running it. 

Damp Dressings. — If the dressings are damp the 
pupil should bravely confess it, dry them on a radiator 
through and through, and take her medicine by staying 
on after hours to resterilize them, having learned where she 
made her mistake. It must be made very impressive 
on these pupils' minds that dressings not sterilized may 
convey death to a patient as surely as a dose of prussic 
acid, and that dampness means no sterilization; worse 
than that, a gateway through the moist covers favorable 
to the entrance of disease-bearing bacteria. In the 
operating-room atmosphere pupils are prone to forget the 
living human being in the wards below for whom they 
exist. It is very wholesome, therefore, to have the 
operating-room staff relieve on the wards at regular 
times to observe the cases they have seen operated on, 
and to acquire an interest in the cases coming up to them. 
This takes away the danger of simply rushing goods 
through on a time-limit without caring whether they are 
done properly or not. By the way, when the pupils go 
to the wards to relieve they should display some skill in 
readjusting themselves to those conditions instead of 
loafing and putting on superior airs. 

Dressings, gloves, gowns, and towels are now steril- 
ized once a day for three days in succession in order to 
kill not only the germs but their spores. This necessi- 
tates a careful planning of cupboards and closets with 
wire doors for ventilation, so that what is finished (the 
third time) cannot be confused with what is run through 
only once. It defeats our object to let the unfinished 
goods lie around carelessly, exposed on dusty tables or 
open shelves or in a damp room. Whether put up in 
drums or loose in the older style sterilizer, they should 



116 OPERATING ROOM 

be marked, "Sterilized once, Jan. 10th/' "Sterilized twice, 
Jan. 11th," and "Sterilized three times, Jan. 12th." 

Mechanical Cleanliness. — The greatest care must be 
taken to procure ordinary mechanical cleanliness com- 
bined with sterilization. One must keep away all dust, 
K. Y. lubricant, liquids, particles, etc., from the goods to 
be placed around a wound. It is a great mistake to 
thrust a dusty bundle into a sterilizer thinking that will 
cure all defects. While operating, emptied covers should 
be collected in a basket and promptly sorted. 

Covers for dressings are made of stout unbleached 
muslin of two thicknesses, with the name of the con- 
tents written or stencilled in ink on the outside. These 
covers are carefully stitched around three sides on the 
wrong side, then finished on the right by turning and 
closing, and present a good appearance. The oftener 
they are washed, the longer they stand the heat. It has 
been proved by bacteriologists that a germ cannot travel 
through a double cover within a reasonable time. A 
cover 12 inches square will hold six ordinary flat 4-inch 
gauze compresses, with plenty of room to open the pack- 
age aseptically, i. e., without touching the inside of it, 
The gauze is laid diagonally in the center, the first corner, 
then the two sides laid over, then the fourth corner folded 
over, tucked in flatly and deeply, then fastened with 
two pins, each buried with one insertion. 

The nurse can here be shown a little point in preserv- 
ing asepsis. If a pin were put in in the usual way, with 
two or three jabs, a person handling that bundle in the 
workroom might contaminate the exposed part of the 
pin with germs from the floor or the finger-nails. When 
the pin is pulled out this would be carried inside the 
cover directly to a compress, which, being used to sponge 
vigorously, carries the same germ deep into the wound. 
A little red ink or blue chalk would represent such germs 
on the exposed part of the pin. 

Caps, Masks, Glasses. — The pupils must wear cool, 
tight-fitting caps of sheer lawn covering their hair en- 



ASEPSIS 117 

tirely to prevent dandruff from falling on the sterile table. 
They should adhere strictly to this, no matter how try- 
ing it may be to their persoual appearance. They must 
also stand erect, and not have any more of their person 
than can be helped over the table. In a recent case of 
intravenous infusion the arm was badly infected with a 
persistent condition locally which did not proceed from 
the saline. There was a moderate purulent discharge, 
followed by a ringworm appearance, which could only be 
accounted for by the possibility of dandruff, since three 
surgeons had their capless heads together over the arm, 
looking for the small vein. Ringworm treatment finally 
cleared it up after ten weeks' duration. By co-opera- 
tion between operating room and laboratory the pupils 
learn what scarf-skin or dandruff looks like, or what 
effects either produces when injected into a guinea-pig. 
Besides, germs abound in the hair, which cannot be treated 
like the hands, therefore it should be kept very closely 
confined. To the good surgeon, good on the basis of 
working for the best results, the best-looking nurse is the 
one dressed most becomingly for her task. The operating 
room is a good place to study character, where people are 
stripped of some of their masks, and, working at high 
tension and unable to keep on guard, show themselves in 
their true colors. 

The surgeons' caps and masks should be laid on the 
scrub-up stands, so that they may don them imme- 
diately after changing from their street clothes to their 
wash suits, but before they scrub and before they don their 
gowns. It is bad technic to have a nurse put one's cap 
and mask on after the gown and shake dandruff down on 
it. The caps should cover the hair completely, but be 
of light goods to minimize perspiration. Perspiration is 
of a very dangerous nature, containing, as it is an elimi- 
native agent, all the poisons of the body. The operating 
room must be quite warm for the patient's sake, and high 
tension in work makes most men perspire profusely. 
The pupil who acts as "dirty nurse," or "unscrubbed," 



118 OPERATING ROOM 

must move quickly when a man perspires. She winds a 
clean hand towel, not a dressing towel, around her right 
wrist so as to leave no floating ends, and as the surgeon 
leans his head away from the table, out of line with his 
body, she very firmly and slowly wipes, just as she dries 
her own face, with deep systematic strokes, not with faint 
tickling dabs (see Fig. 3). The operator's glasses must 
not be disturbed, since he prefers to set them himself, 
but his hands are in the wound. Blood on the glasses 
necessitates their removal and return after being washed 
with cold water. It is an awful catastrophe to drop them 
or break them with hot water, because that virtually 
blinds some men. Boric acid and argyrol (25 per cent.) 
should be kept in case of chances of infection from blood 
or pus. 

Tests by Cultures. — Cultures should be taken from the 
nails of the surgeons and nurses after scrubbing up at 
irregular intervals. Some of the results are very appalling! 
Some hospitals have a "test day/' when the pathologist 
comes to the operating room and takes cultures from all 
sorts of places — the door-knobs, saline solution, the hands 
of the staff, the buttons on the light switches, the dress- 
ings, etc. — to show the actual existence of bacteria. The 
operating room is a sort of clearing-house for bacteria in 
the hospital, anyway. Other institutions have a "moni- 
tor," a junior intern probably, appointed to come unex- 
pectedly to watch for breaks in technic, to see if anyone 
who is at all concerned with the wound touches any- 
thing unsterile or if any sterile goods become contami- 
nated. One set of pupils receive sufficient instruction from 
one set of cultures; i. e., these visits can be made once 
each quarter, during the senior's last and the junior's 
earlier weeks. 

There is a great inconsistency in the preparation of 
various kinds of goods by sterilization. The time limit 
and the number of pounds of pressure vary for rubber 
gloves, gauze, and iodoform packing. Then, too, in some 
institutions gloves are boiled. Sometimes sharp-edged 



ASEPSIS 119 

instruments are merely soaked in pure carbolic acid and 
alcohol or in lysol. Some hospitals use doubtful sub- 
stitutes for lysol because they are cheap. It is the busi- 
ness of the pathologist to show the pupils that there are 
certain goods which can stand a long period but not a 
high degree of heat, and that the result is as good as if it 
were a shorter time and a higher temperature. We are 
told that a properly tempered steel blade is finished at 
500° F., and that no boiling can spoil it; but not many 
hospitals buy blades as fine as that, and theirs are spoiled 
by boiling. 

The basic principles in bacteriology are quite uniform 
throughout the world, and if the pathologists were pressed 
into service by the Medical Boards the technic for 
sterilization could be decided on in a way that would be 
almost uniform everywhere for each class of goods. It 
should be so simple that the average mind could easily 
comprehend it. 

Tracing the Aseptic Chain. — Asepsis for the operating 
room should present the picture of a chain in the pupil's 
mind, each link being clean and free from germs to such a 
distance that it would be impossible for them to "crawl" 
or "fly" across or "fall" into the wound, or be carried 
thither by a swift random gesture of an assistant. 

The skin is disinfected with iodin (2.5 per cent.) and 
alcohol (95 per cent.), the umbilicus being left in abdominal 
work to the last, and the sponge stick then thrown aside. 
Towels then bounding this area are now thrown aside 
also, and the new ones are unfolded (Fig. 16) at the level of 
the patient's body and not until the patient is reached 
(Fig. 17). They had lain on a sterile table freshly set up. 
They did not touch anything unsterile in transit. They 
came out of a package opened by the unscrubbed nurse in 
such a way that her hand did not touch the inside of 
the bundle. She pinched the corners in turn exteriorly, 
pulling them back like a snap-dragon. 

The knife making the incision had been sterilized and 
laid on the sterile table; it had been handed to the sur- 



120 



OPERATING ROOM 



geon's hand by an assistant whose gown had long sleeves 
and whose gloves were pulled on by the inside of the 
wrists, as they are done up in their packages, so that his 
bare fingers never touched the outside. 





Fig. 16. — Opening towel properly folded (to the center twice). 

The basin in which the surgeon occasionally rinses off 
his bloody gloves was steam-sterilized and lifted out by a 
nurse, either with forceps or holding it only by the out- 
side, and supporting it from the bottom while being filled 
with sterile water at the sterilizer faucets. These basins 



ASEPSIS 121 

lie face down in the utensil sterilizer so that the steam will 
rise into them. The scrubbed nurse takes out what 
goes on the sterile tables, and the unscrubbed nurse what 
goes on the tripods. 







Fig. 17. — Laying a sterile towel by the field of operation, opened 
only after passing the surgeon. 

The moment an incision is made none of these things 
are any longer sterile, yet the operation proceeds with 
asepsis. Contact with the patient's blood and tissues has 
contaminated all the assistants, but they do not bring any 



122 OPERATING ROOM 

other germs to the patient. But his blood may contain 
typhoid, syphilis, or tuberculosis, and if injected into 
another living being might cause instant death. A surgeon 
should not say, "I can't write it now, I'm sterile/ 7 because 
he is not sterile any longer after he has exposed the sub- 
cutaneous tissue. He would not cut out a piece of that 
tissue and rub it in his own eyes. A part from that 
wound might infect the patient's own eyes. Therefore, 
nothing that has touched that patient, or that has during 
the operation been handled by anyone touching that 
patient, should be used in a second case without being 
sterilized again. 

In setting up for a case the nurse should open as many 
packages as she is going to need before she scrubs, to help 
herself as much as she can. Many times in a private 
house she will have nobody to help her. All hospital 
training should point toward competent private nursing, 
and every official in the nursing department should have 
a couple of years of private experience in order to know 
what to prepare pupils to meet. Some pupils are guilty 
of scrubbing, then getting into their gowns, and then de- 
manding the help of another nurse. "Every tub should 
stand on its own bottom" is a homely adage that applies 
well here. It teaches forethought, which is most essen- 
tial in a well-developed character. 

Some Errors in Technic. — It has already been said that 
germs travel through moist goods; therefore, since the 
table covers may be wet by drops of water from the basins 
or by blood, they should both be removed and the glass 
table top redisinfected with carbolic acid (5 per cent.) to 
render inert any bacteria found there before "setting up" 
for a second case. 

Some old-fashioned hospitals "set up" with two table 
covers, one loosely thrown above the other, and these 
are peeled off in turn as the cases proceed. Heaven help 
the last case! But a pathologic expert can at once dis- 
prove the need of this, and its very clumsiness makes it 
dangerous. Others wind table legs with towels so as to 



ASEPSIS 123 

have safe access to a lower shelf. Rather convert this 
time, material, and energy into buying another table. 
Keep all work and materials on a level with the patient. 
Do not buy tables with lower shelves. 

It is a grave error to allow any or all of the working 
force to have access to a table of sterile supplies. If 
there is a large number of pupils in the school, a hospital 
may afford one, as clean nurse, to stand at the sterile 
table (rigidly aloof from all workers or patients), who may 
drop on the work tables, without contact, what is needed for 
the case in progress. But she must touch nothing only 
her own tableful of goods. 

Otherwise, when there is no clean nurse there is an 
absolutely clean start made for the second case. Each 
patient must have all the advantages that the hospital 
can afford. We call a case "clean" where we hope for 
primary union, yet in his blood may be we know not what 
— typhoid, tuberculosis, or lues. Therefore there must be 
rigid watchfulness to keep all separate. 

For, suppose at the beginning of a long morning's 
work we have provided a table of sterile goods without 
a clean nurse stationed at it, observe what happens. 
The scrubbed nurse is not clean the moment after the 
first blood is drawn. She then goes to the table and 
selects some sponges. After the surgeon has finished 
the vaginal work, he, in his blood-spattered gown, leans 
over the table to get a second pair of gloves for the ab- 
dominal work. The scrubbed nurse returns to get some 
abdominal wipes, passing her gloves over the area touched 
by his gown. A smudge of blue chalk on his gown during 
the vaginal work can thus be easily transmitted to her 
sponges for the abdominal work or to a second case. Of 
course, pathogenic organisms, growing and virulent, are 
more easily passed along. Surgeons select the cleanest 
case first, but we never know what incipient diseases 
their anatomy contains. There are only two alterna- 
tives — a clean nurse at the supply table or laying out 
open only what is needed for each case, the extras to be 



124 OPERATING ROOM 

brought by the unscrubbed "floater." In a gynecologic 
hospital the dangers are worse, though less apparent, in 
the form of venereal disease and cancer. 

Where a clean nurse can be afforded, she is all ready to 
wait on the surgeons for the second case, and can take 
instruments also for it, if so it is decided, so that the 
first instrument nurse can scrub and take her place on the 
supply table, then being ready for instruments on the 
third case. 

All the apparatus directly concerned with the pa- 
tient's inhalation of anesthetics should be boiled each 
time it is used, since some of the most dangerous germs 
of lues and tuberculosis are transmitted by mouth, as 
well as tonsillitis, la grippe, and others more speedily 
terminated but more prostrating and annoying, espe- 
cially through the dangers from coughing, inducing hernia, 
and undoing the surgeon's work. 

Some persons when they are scrubbed act as if they 
were sterile; nay, more, as if they were themselves germi- 
cidal, that if a germ lit on them they would blast it w T ith 
instantaneous death. That they care for the patient well 
is true, but it is sadly equally true that they can carry 
infection from that patient to the supplies needed for an- 
other. There are two kinds of caution to take during 
the progress of an operation: (1) Do not come in contact 
with anything that will harm the present patient; (2) do 
not carry anything away from this patient to another. 

How to Handle Goods from a Jar. — When rubber 
tubing, packing, or any other goods are needed that are 
kept in sterile jars nothing that was used on the case should 
be inserted into those receptacles. If a nurse is alone in 
setting-up and assisting the surgeon she must lay out all 
she thinks he will need before he comes, inserting into the 
jars a long forceps kept in lysol or alcohol, as the case 
may be abdominal or eye, and not be stingy about it 
either, for it is much easier to resterilize packing than 
to make a large lot for a drainage case thus caused. It is 
extravagant to resterilize more often than necessary, both 



ASEPSIS 



125 



in time, gas or steam, and deterioration of materials 
(rubber, rubber tissue, etc.), but there must not be a 
central meeting-place for the clean and the unclean in 





Fig. 18. — Pouring out drugs, holding the cork in an aseptic manner. 

"sterile" supply jars. This long forceps, kept scrubbed 
with Bon Ami every day and dried out at night to pre- 
vent rusting, takes the place of a clean nurse. Lysol 



126 OPERATING ROOM 

(2 per cent.) is strong enough to render them germ free, 
but should not be carried into an eye solution. Rinsing 
in sterile water is necessary. If jar lids must be laid down, 
the sterile side is left uppermost so as to touch no unclean 
thing (Fig. 18). 

A dram of any drug to a pint of water makes a 1 per 
cent, solution. But why is this? To know why means 
that one never forgets this rule: 

1 per cent, means rib"- 

In 1 pint are 16 ounces, or 128 drams. 

Tiro of a pint = tw of 128 drams, or IyA drams. 

TFU, about |, is a sufficiently small fraction to be dis- 
regarded in small solutions, the pathologists say. In 
making up solutions, the amount should always be cal- 
culated on paper and submitted to the supervisor for her 
0. K. Women ordinarily have very little mathematical 
ability, and if the nurse can be made to feel the dangers 
of a mistake and a doubtfulness of her own arithmetical 
powers, much will be avoided that is shameful and un- 
pleasant. All the containers in the operating room should 
be measured with graduates — ounce, pint, or gallon — 
often enough to know at once the contents of any ordinary 
vessel by the eye, and then in working a graduate should 
always be used. 

In setting-up for operations, too, the old rule must 
be observed thoughtfully, not with one's mind on the 
play or the dance of the night before — "Read the label 
three times." What was the nurse thinking about who 
filled the bichlorid arm-tank for an obstetrician with 
pure carbolic acid? Nobody can estimate the loss it 
caused to the physician, to the patient in labor, to the 
nurse herself, to the women of his private practice, hoping 
for the advantages of his own personality, so strong in 
obstetric work, when it came their turn. The institution 
loses in prestige, all by one moment's lapse on the part of 
the nurse, who could not have done it if she had been early 
forced into a groove of thoughtful habit. 

To put a bell on poison bottles, or to stick a long pin 



ASEPSIS 127 

through their cork, acts as a good warning to nurses who 
do not keep their mind on their work. 

Dusting. — Care must be regularly taken with the high 
dusting first thing in the morning, so that no foreign body 
can fall into the wound from the fixtures. Owing to the 
laws of physics governing air, heat, dust, etc., it is diffi- 
cult to believe that any area over an operating-table is 
clean, but the nurse must prepare the overhead space 
perfectly, so as not to make her other work useless, in- 
stead of shunning it and leaving it to the orderly. 

Orderlies. — Many times there will be a change of 
orderly, or days when none is to be had. The new ones 
must be thoroughly taught and watched afterward; 
this last without their being aware of it. It is not going 
to hurt any nurse to mount a solid stepladder or table 
and dust the chandeliers; but when an orderly is on duty 
it must be done to the same degree of perfection to the 
nurse's certain knowledge. The orderly is a very un- 
pleasant factor at times in the working of a hospital, 
since it is a dependent, parasitic existence for an able- 
bodied young man in these days when the trades com- 
mand such good pay and securities in the form of work- 
men's compensation. It is not safe to assume anything 
about an orderly's intelligence or conscience, and the 
nurse must see that his work is thorough. Yet there 
are a few simple, faithful souls who take a humble pride 
basking in the effulgence reflected from a great surgeon, 
working with zest to share in the results behind the 
scenes that ensure his brilliant successes. 

It is very dangerous to the purity of the air to have 
vents in a glass dome roof or curtains sliding on a sky- 
light to darken a room for the use of "scopes," or a ven- 
tilating fan near the ceiling, set in commotion during an 
operation. The scene must be all set before the case 
comes on as to air, light, and heat. 

The anesthetist has been sometimes walled off from a 
view of the wound, but this has its disadvantages. The 
gain in asepsis is more than counterbalanced by his loss 



128 OPERATING ROOM 

of control when he cannot see how far his patient's 
abdomen is relaxed. Better discipline the one curious 
gazer who forgets his anesthetic in interest in the wound 
than deprive ten good anesthetists of their chief gauge of 
control. The anesthetic may be as fatal in, its termina- 
tion as the wound, and must have free play. 

The anesthetist changes, with the other men, into a 
clean white suit and cap to save his own from odors and 
vomitus, as well as to exclude from the operating room 
all germs of the trolley car or pavement — i. e., scarlet 
fever, tonsillitis, la grippe, etc. 

Contaminated Instruments. — During an operation if 
any instrument becomes contaminated with pus it should 
be dropped, not on the floor, but into a floor basin, whence 
it is carefully taken to be washed and reboiled by the 
nurse. Towels that become thus contaminated are 
carefully drawn away from the wound, not flopped about, 
then rolled up, disinfected, and washed in the hopper, so 
that bacteria have no time to spread. It is very foolish 
to get all the towels and instruments smeared with 
pus in a dirty case. It can with a very little thoughtful 
care be mopped up, dammed up, and disinfected. This 
practically renders this case innocuous to all following it 
as to the general furnishings, the tables and tripods and 
irrigating stands not being smeared. 

Breaks in Asepsis. — Everyone in the working staff 
should be on the "qui vive" for "breaks" in aseptic 
technic. Among surgeons the word "technic" means the 
method of incising, ligating, extirpating, etc., in classic 
operations — i. e., the direction and length of the wound, 
the materials used, and the instruments required. But 
in nurses' slang the word "technic" means their share in 
the operating room in preserving asepsis. Instead of 
saying "break in technic" the phrase "break in asepsis" 
should be used. It is unfortunate that this confusion of 
terms has arisen. Let each one try to head it off. At any 
rate, all language should be clear, forcible, and uniform. 
A dressing cover is not a "skin" but a dressing cover. 



ASEPSIS 129 

What is a "probang"?. What is a "whistle"? Each 
article should be named by its shape, material, and use. 
Yet so monotonous is routine that nurses fasten delight- 
edly on the new language of the operating room and use 
it to the point of boredom. 

The operating-table makes a lodgment for all the bac- 
terial content of drainage, irrigations, and ordinary con- 
tact with dressings and towels. It requires thorough 
washing with soap and water and carbolic acid (5 per 
cent.) between cases, and a brisk whitening or polishing 
with Bon Ami each evening. 

Floors are more satisfactory if white at all times. 
Between cases they are mopped, first with cold water to 
remove blood, then with clean water and soap, then 
with carbolic acid (1 : 40). This requires three different 
mops. The head nurse supervises the care of these 
mops with extreme vigilance, because not only is blood 
a first-class medium for germ culture, but where the 
operators wear street shoes instead of sneakers, or do not 
wear goloshes, millions of tetanus germs are carried in. 
These mops require washing and boiling, then sunning 
and airing. The unscrubbed nurse should be proud to 
wield a mop during the progress of a case — to prevent 
sloppiness and head off infection, to show that she has an 
interest in the case. A w^ell-equipped suite has a hopper 
room with boilers for various utensils such as these. . The 
white, small round peppermint lozenge tile finds most 
favor. It shows its cleanliness and is easily repaired. 

The few stands and cases which the operating room 
holds must be thoroughly cleaned once a week, and 
always pulled out on their large, strong, noiseless casters 
to get at the walls behind. The instruments are boiled 
after each case before being laid on the shelves. 

The walls collect dust, and require brushing every week 
and washing every three months. To disinfect the whole 
room by modern equipment there is a simple device con- 
trolled by the engineer from outside, by which, when the 
room has been sealed externally, live steam is turned on 

9 



130 OPERATING ROOM 

and fills every corner, destroying every germ and spore 
better than any other known agent can do. Some 
hospitals permit the ghastly mistake of simply washing 
and drying instruments without boiling them before 
laying them away. This conveys many bacteria to the 
case shelves, w T here in the very humid atmosphere they 
multiply to the millions. One could reasonably expect 
primary union in an emergency operation if the instru- 
ments had been boiled when put away on shelves pol- 
ished with alcohol a day or so before. There is no excuse 
for these errors if nurses would but use their brains and 
apply what they hear (but do not heed) in their lectures 
on bacteriology. 

Shoes. — Some surgeons do, and all should, wear special 
shoes for operating-room work of a style and shape that 
will not induce fatigue. As nurses do not wear their 
hospital shoes on the street, they do not require special 
footgear for the operating room. But every nurse 
should keep on hand two pairs in good condition, however, 
so as to change in her time off for the purpose of reliev- 
ing the feet of perspiration or heat and of airing the shoes 
in a sunny window. To secure efficiency in her staff a 
careful head nurse will watch and assume her authority 
in these points. 

Health of Attendants. — It is imperative that each 
person taking part in the care of the operating room 
should be in perfect health. In one instance the men 
employees lived in the basement of the nurses' home, 
w T here the strong odor of burning calomel was observed 
for a whole evening, coming up from the room of the 
operating room orderly through the hot-air radiators 
which communicated with the nurses' rooms. He was 
treating himself for an attack of lues on a prescription 
from one of the interns in the hospital dispensary who had 
not deemed it necessary to report the affair "for fear the 
man would lose his job." Such orderlies should be given, 
on the slightest suspicion, a complete physical, not verbal, 
examination. Such interns should be suspended. 



ASEPSIS 131 

Emergency Cases. — If rases arc brought off the street 
for immediate surgical relief, in those institutions which 
now so admirably meet the instant needs of their con- 
stituency, these sufferers can be cloaked by large gowns 
over all until after the operation. But there must be 
sincere and sympathetic co-operation between the office 
where operations are booked by the surgeons and the 
operating room. A case should not be rushed to the oper- 
ating room as an emergency if it is not an emergency. 
But the operating room should always be instantly and 
cheerfully prepared and the work done, and if deceived 
a protest calmly entered afterward. There is no doubt 
that a woman capable of conducting an operating room 
has a sound, sane mind, and should have a reliable court 
of appeal to take her troubles to. If she does her work 
well, she is of more value to the hospital than any surgeon 
is w 7 ho stoops to deceit. Careless diagnosis is just as 
culpable as deceit. The office or, in other words, the 
business superintendent must not expose all his patients 
to the dangers from overhaste with the one. He may be 
quite too anxious to cater to the whims of one attending 
or director, and overlook the axiom of "doing the greatest 
good to the greatest possible number, " forcing irregulari- 
ties on the operating room that may prove it a menace 
instead of a means for relief. 

Contagious Cases. — Sometimes it is humane and im- 
perative to admit a case of scarlet fever requiring an im- 
mediate mastoid operation from a home too poor to make 
the work possible. In such a case the city should provide 
special nurses if there are not enough pupils. An isolated 
room can be quickly fitted up as an operating room in a 
sanitary manner and the patient put to bed there after it 
is finished. Many towns are not w r ell equipped for the 
care of contagion, and the philanthropists expect the 
hospital to meet all these exigencies. But the oldest 
nurse will emphatically state that w T hen a humane act 
is performed in the midst of contagion harm seldom comes 
of it. But such conditions should be a potent argument 



132 OPERATING ROOM 

for building an isolation hospital. There should be a 
small, flexible committee to govern operating-room 
affairs, consisting of the less and the greater surgeons, the 
superintendent, the directress of nurses, and the operat- 
ing-room supervisor. The directress of nurses is respon- 
sible for the health of her nurses and their work. If 
there is any " crooked work" in the operating room she 
cannot be compelled to provide nurses for that service, 
since the state does not specify this nor interrogate candi- 
dates for the degree of registered nurse on the problems 
of that service. She also can, through the operating-room 
supervisor, control any foreign nurses thrust in by a 
hostile superintendent. If, then, any steps have been 
taken through greed rather than altruism and humane 
feeling to put undue burdens on the operating room, 
rendering it unclean and slow in service for later cases, 
this committee can, by talking the matter over, adjust it 
and prevent a recurrence. 

It is not proper to ask an operating room to sterilize 
supplies made in a home where contagion exists, nor the 
blankets, etc., used on a contagious case. Other means 
must be employed. This is a duty of the Board of Health. 
Every modern town should have public means of disin- 
fecting anything. There is no emergency connected 
with the disinfecting of a mattress. Public aggrega- 
tions of infection must not be brought to the hospital 
where people come trustingly to be operated on while 
weak and ill. 

"Clean" Cases. — An emergency off the street is "clean" 
in the true sense of the word. A grimy coal-heaver with 
a broken leg is a clean case, where a dainty child with a 
ruptured appendix is a dirty case. The coal-heaver may 
have been inoculated with the tetanus germ off the ground, 
but the moment he comes in he is given a dose of tetanus 
antitoxin. But he must get absolutely sterile dressings, 
catgut never opened before, and newly sterilized towels, 
with gowns, caps, and all the "pomp and circumstance of 
war" against bacteria. Well cloaked, he is no menace to 



ASEPSIS 133 

the interior. But a woman with puerperal sepsis is a 
menace to everybody, and should not be treated in an 
operating room where eye w T ork, bone-plating, and 
hernias are done, since her infection is powerful, in- 
sidious, and dangerous. 

It is wise to have a small room with complete but 
modest equipment in which to segregate what are known 
to be septic cases, and to disinfect it with live steam when- 
ever it is used. 

Nurses Who are 111. — Nurses with tonsillitis, la grippe, 
infected fingers, et al., must be kept out of the operating 
room. Neither are the wards a safe place for them, since 
they are now, when ill, more susceptible to the infections 
of the patients. Where can they go? Off duty. Feed 
them properly and keep them well. House them com- 
fortably, then watch their conduct. Inculcate the idea 
of dressing warmly around the neck and limbs so as to 
reach a healthy, graceful prime, and levy a heavy penalty 
for time lost by ill-health. The operating room owes the 
patient a duty and must not load him with additional 
disease. 

Catgut is a fertile source of trouble, since it is an animal 
product. The equipment for making catgut is very ex- 
pensive and the responsibility is very great. No amount 
of money can buy nurses in these days of women's rights, 
and equipment is always cheaper than human blood or 
brains. Buy the catgut from a reliable firm, and do not 
heap on the nurses a burden that has no connection at all 
with their work as private specials in the homes. The 
men who make catgut for the firms who deal in it have no 
other responsibility. They have no life-saving work to 
do; their hours are regular and they are trained for only 
one thing. But if catgut is made in a hospital, and a 
surgeon with a boil on his finger gets an infection in the 
hernia he has operated on, the vials of his wrath are un- 
justly let loose on the nurses. Some firms sell good 
catgut. Buy only from them. Do not change for lower 
prices. The supervisor must follow the cases and see 



134 OPERATING ROOM 

what is the effect with different kinds of catgut. It is a 
well-known fact that some penny-wise, pound-foolish 
hospitals have changed over to cheaper catgut, and have 
had a run of insidious, annoying, pride-reducing infections 
in what should have been primary union, not deeper, 
and, therefore, surely due to the catgut. This is rank 
robbery of the patient's time and money through length- 
ening his stay. The operators have an uneasy feeling as 
well as their colleagues outside who send the cases in. 

Gloves and towels with holes are not only no good, but 
harmful. All holes must be mended. Tapes and buttons 
are sewed on gowns in order to fasten perfectly, since 
sloppy gowns trail over everything. If a surgeon finds 
that he has slit or pierced his glove during a case he must 
change it at once; otherwise it lets out into the wound 
all the poisons excreted in his perspiration and collecting 
there for one-half hour in a warm moist bed for bacteria. 
Perspiration itself acts as a foreign poisonous body also. 
Each nurse should become an expert in mending gloves 
smoothly and solidly. A package of sterile powder is 
done up inside of each glove case. They are opened by the 
dirty nurse in such a way that she does not touch the part 
whence the surgeon withdraws the glove (see Fig. 1). 
They may also be opened while "setting-up" and laid on 
the table beside the instruments, from which the surgeon 
must not take them with his bare fingers. The instrument 
nurse hands them to him. Dry sterilization is much 
more speedy and comfortable for the surgeon, but it runs 
the bills up because it ruins rubber. Boiling the gloves, 
or "wet technic," is much cheaper and, like many other 
things, more uncomfortable. The surgeon first takes 
the powder out, dusts it over his fingers, then pulls on the 
dry gloves by their inside surface, the wrists being folded 
back. 

A strict technic must be observed with bottles, jars, 
and shakers, which can only be perfected by constant 
criticism and practice. A solution of cocain or adrenalin 
must not be heated, but it can be kept sufficiently clean 



asepsis 135 

to be harmless with a little care. The cork can be held 
in the little finger of the left hand while pouring. The 
top side of a shaker should not be laid down. A jar lid 
is laid down upside down. When preparing to shake 
aristol over a raw wound wet a towel in bichloricl, and, 
winding it around bottle and wrist so as to cover any dust 
on their surfaces, shake gently over the bleeding area. 

Sterile goods must not be carried under the armpit 
on account of perspiration, any more than we w T ant a 
maid to run with bread from the baker's under her arm. 

Tap-water is quite clean enough for the bichlorid 
tank, since the drug kills all the bacteria in the water 
easily. It takes a big load off the water sterilizers to know 
this. Furthermore, economy can be exercised in using 
70 per cent, alcohol, which is just as effective as 95 per 
cent., and less costly by about one-fourth the price. 

Every year marks an added simplicity in operating 
technic; for instance, comparing the slops of ten years 
ago — big wet abdominal dressings, irrigations, and 
douches — with the present dry method — no irrigation, 
no cleansing with green soap, merety painting a little 
iodin over the crusts around a cut. The results continue 
to improve, and each worker in this field should observe 
much, compare all, and contribute any original idea she 
has for the common good. 



CHAPTER X 

FORMULAE AND DIRECTIONS 

Thiersch's Solution. — A valuable antiseptic for nose 
and throat: 

Salicylic acid. . . . 2 parts. 

Boracic acid crystals 12 parts. 

Water 1000 parts. 

Carrel-Dakin Antiseptic. — Dissolve 140 gm. of an- 
hydrous sodium carbonate in 10 liters of water. Add 
200 gm. of chlorinated lime. Shake the mixture thor- 
oughly, and after one-half hour siphon off the super- 
natant fluid from the precipitate of calcium carbonate. 
Filter this fluid through cotton. Make the clear fluid 
neutral or acid by adding boric acid, drop by drop, until 
a drop of the solution does not redden a few drops of 
phenolphthalein solution. Usually this requires 25 to 
40 gm. boric acid. 1 

Iodoform Packing (I). — 

Iodoform powder 15 c.c. 

Normal saline 120 c.c. 

Carbolic acid solution (5 per cent.) 3j- 

Tincture green soap 5ss. 

Glycerin § ss. 

Sterilize in open jars for twenty minutes at 15 pounds; lids be- 
side jars in the dressing sterilizer. 

In making iodoform gauze the cloth will have been 
previously drawn, ravelled, or folded in odd half- 
hours in the anesthetic room, or by special nurses with 
leisure and willingness to help. Bandages are ravelled 
at the ends to leave smooth, threadless borders, because 
1 American Journal of Medicine, September, 1915. 
136 



FORMULA AND DIRECTIONS 137 

threads in a granulating wound or a curetted uterus delay 
healing, acting as a foreign body. The fuzz is snipped off 
so that the remaining part will exactly measure, when 
spread out single, |, 1 inch, or 2 inches, as labelled. The 
plain gauze is then sterilized once in muslin covers or in 
open jars in 12-inch to 5-yard strips for ears, uteri, etc. 

The drugs of the formula are mixed with a sterile 
spatula in a sterile glass graduate, using a sterile minim 
glass to measure small amounts, then poured into a flat 
glass basin, also boiled. The powder is thoroughly emul- 
sified in the green soap and glycerin before adding the 
watery solutions. No stain is left on glass. 

The glass table is then "set up" with an opened pack- 
age of towels, of packing, sterile brown glass jars, and 
the mixture. The nurse scrubs, lays a towel on the table, 
brings her materials upon it, and begins folding the gauze 
in plaits until it absorbs the mixture in all parts. Then 
she squeezes out all she can and lays the pieces in the 
jars. 

Iodoform Packing (II). — 

Iodoform powder „ . . . 5 v. 

Glycerin .. gj. 

Bichlorid of mercury solution (1 : 1000) % v. 

Sterilize in test-tubes with a cotton plug and a muslin cover for 
twenty minutes at 15 pounds in the dressing sterilizer. 

Preparation of Catgut. 1 — Plain catgut is used in tissues 
which absorb very rapidly and where the strength of the 
union will not have any strain. 

To iodize catgut increases its tensile strength. Chromic- 
ized catgut is hardened to a still greater degree than the 
plain and absorbs more slowly, therefore the line of 
union is much stronger because the patient's tissues do 
their own uniting. Chromic gut is due to be absorbed in 
the time mentioned on the label, as ten, twenty, or forty 
days. The union of tissue sutured with ten-day is usually 
satisfactory, the others being used for ligatures. In a 

1 See Dr. Brickner's comprehensive work, "The Surgical Assist- 
ant." 



138 OPERATING ROOM 

perineum after laceration by childbirth great strain is 
felt at each stool, therefore chromic gut is used. 

Kangaroo tendon is always chromicized and is very 
strong. It is used to suture bone — e. g., a fractured 
patella — in place of the old silver wire; also aponeuroses 
or ligaments, as in inguinal and femoral hernia. These 
various kinds of gut are bought in chloroform in tubes, 
boiled before using. 

Horsehair acts like silkworm-gut. It is boiled before 
using and keeps in alcohol. Horsehair sutures are to be 
removed. 

Silkworm-gut may be boiled as used and carried dry 
in a physician's kit, or boiled and kept in alcohol in an 
operating room. It is used in scalp wounds, in a mastoid, 
and in perineorrhaphy. It is of two colors, white and 
black, white showing up well in negroes, and vice versa. 
The black should be iron-dyed to secure a fast color. 

Surgeons' silk should be threaded in 15-inch lengths 
in all grades of strength on all needles suitable for wounds 
requiring silk, and then run through a hemmed square 
of white flannel, afterward dry sterilized, but not too 
often, since the dry method rots the silk more than 
boiling. But this saves the trouble of threading during 
an operation. 

Bone-wax is boiled for ten minutes, then poured into 
a second sterile -dish, cooled, covered, and wrapped in a 
sterile towel to be carried about. It is so rarely used in 
a general operating room that the surgeon needing it 
should bring it. 

Aluminum Acetate Solution. — 

Plumbi acetate 3.5 

Alumen. 9.0 

Aqua... . . . ...:........ ad 100.0 

Mix and filter. 

Dilute when using with five to eight times as much 
water. Never use it full strength. It macerates the skin 
and its ingredients are costly. Gauze is moistened, then 



FORMULA AND DIRECTIONS 139 

laid loosely on the part, then the limb is laid on a rubber 
sheet and covered with a high cradle to let air circulate 
and evaporation take place, which causes reduction of 
temperature. Do not wrap up in rubber. 
Boric Acid Solution. — 

Boric acid (crystals preferably) 4 parts. 

Water 100 parts. 

Boil until clear. To use, add an equal amount of sterile water. 

Pharmacists employ the cold process by adding the 
powder to cold water and letting it stand and absorb until 
a sediment remains (supersaturated). 

Normal Saline. — Salt exists in the blood in the pro- 
portion of 9 parts to 1000, or to per cent. It is not neces- 
sary to say ro of 1 per cent. — it is a reflection on the in- 
telligence of the listener. 

Normal saline is a solution which contains as much salt 
as blood does, and it is used to take the place of blood 
after hemorrhage or to stimulate after shock until, by 
taking food, the patient can manufacture new- blood. 
In 1 quart are 32 ounces, or 256 drams, or 15,360 grains; 
ro per cent, of 1 quart = to of xio of 15,360 grains = 
138 grains. In 1 quart of blood are 138 grains of salt, 
therefore to make 1 quart of normal saline we add 138 
grains of salt to 1 quart of water and boil it for five 
minutes to dissolve thoroughly. Filter now when cooled 
through sterile cotton and sterile filter-paper, regularly 
plaited to fit into a funnel that has been boiled, into a set 
of Florentine flasks of 1-pint, 1-quart, and 2-quart sizes. 
These have been cleansed with a bottle brush and tinc- 
ture of green soap, sterile water, alcohol, and a final rins- 
ing of sterile water, and stoppered with cotton plugs until 
ready for use. Or, dissolve the salt in the proper amount 
of distilled water, which if kept under aseptic conditions 
will minimize bacterial activity in the solution. Am r 
and every hospital should have at least a simple distilla- 
tion apparatus for use both in the pharmacy and the 
operating room. 



140 OPERATING ROOM 

In transferring saline solution to the flasks the nurse 
should "set up" a sterile table with sterilized cotton, 
gauze, tapes and utensils, and cleanse her hands as for 
operating. When the flasks are filled, only in the round 
part of the body, they are set on the floor of the dressing 
sterilizer and sterilized for one-half hour at 15 pounds for 
three days in succession, care being taken to mark them 
as being done once, twice, or thrice. If at any time crys- 
tals or cloudy spots are visible the solution should not 
be used. The brilliant clarity of well-made saline is 
always very noticeable. 

Bichlorid of Mercury Solutions. — 1 pint = 7680 
grains. Pathologists have found that many of these 
powerful drugs have germicidal power at the strength of 
1 part of the pure drug to 1000 parts of water. 

tto¥ of 1 pint = roVo of 7680 grains = l^i grains, 
nearly 7| grains; therefore any drug dissolved in water in 
the proportion of 1\ grains to 1 pint makes a 1 : 1000 
solution. 

1 : 2000 is much weaker. One man against two thou- 
sand foes stands a worse chance than one man against 
one thousand, twice as bad = half as favorable. To 
make a 1 : 2000 solution we therefore add 2 pints of 
water to 1\ grains of the drug. Or, use one-half of the 
amount of drug to the pint of water. One-half of 1\ = 
\ of "V 5 ~ = J 4 5 - = 3f grains to 1 pint of water. But nurses 
must never break tablets to get smaller dosage. Dissolve 
1\ grains in as small an amount of water as possible and 
take one-half of it, then add 1 pint of water to make 
1 : 2000 solution. 

1 : 500 solution means more drug to 1 pint or less 
water to 7| grains, in the proportions of twice the amount 
of drug or one-half the amount of water, i. e., 15 grains to 
1 pint, or 7| grains to | pint. 

Where bichlorid of mercury is frequently used in weak 
solutions it is economic to keep a bottle of 1 : 1000 solu- 
tion on hand, made up daily, for it deteriorates. We 



FORMULAE AND DIRECTIONS 141 

then compute thus: For a vaginal irrigation we need 
4 quarts of 1 : 6000 solution of bichlorid of mercury. 

A solution 1 : 6000 is five times weaker than ( = six times 
as weak as) a 1 : 1000 solution. One-sixth of the total 
amount is 1 : 1000 solution, the rest water. Our total is 
4 quarts (4 X 32 = 128 ounces); f" of 128 ounces = 21-J 
ounces. Take 21 ounces of 1 : 1000 solution and add to 
it 3 quarts 11 ounces of water for a total of 1 gallon. 

It is very unsafe to keep strong solutions of mercury 
about. There may be undue haste in measuring them. 
Too strong bichlorid solutions act as an escharotic and 
corrode the flesh instantly. 

Formaldehyd is a gas that is soluble in water in the 
proportion of formaldehyd 40 parts to water 100 parts. 
This solution is called formalin. Other fluids are sold, 
such as formacal, having the same ingredients, but not 
daring to use the original trade name, which has certain 
commercial rights and limitations. Specimens for the 
laboratory are almost universally kept in formalin. It 
does not shrink the delicate tissues of an eye. Alcohol 
does. Yet it preserves and hardens for section-cutting 
satisfactorily. Specimens must be placed in wide- 
mouthed bottles with good corks to prevent evapora- 
tion and concentration of the drug and consequent de- 
struction of the tissue. 

Formalin is 40 per cent, formaldehyd; 4 per cent, 
formalin for specimens means 4 parts out of the bottle 
labelled formalin and 96 parts of water. It does not 
matter how much formaldehyd is in this, but, to be 
definite, a 4 per cent, solution of formalin contains tito 
of tVo of the amount of formaldehyd = nHr o", or 16 parts 
formaldehyd gas to 1000 parts of water. Use it spar- 
ingly. It is expensive and hard on the eyes and skin. 

Nitrate of silver is best handled in tablets. They 
deliquesce when exposed to air and deteriorate if ex- 
posed to light, therefore must be kept in a dark blue 
or brown bottle tightly stoppered with glass and cot- 
ton. As the labels must contain a large amount of 



142 OPERATING ROOM 

necessary information, the print is consequently very 
fine and mistakes can easily occur. In one instance a 
nurse interpreted grs. 5 to mean gr. .5, or gr. |. She was 
distinctly wrong, because the s indicated more than 
1 grain. But, being in doubt, she asked an intern who 
came from one of those states where, though there is not 
woman suffrage, the gentlemen always agree with the 
ladies, and he said grs. 5 meant gr. |. Therefore she 
made up a solution for bladder irrigation ten times as 
strong as it should have been, causing the patient great 
pain. Had it been a primary lesion he would have died, 
but being an old man with a very old infection he escaped. 
This saved her shoulders, but not her conscience. 

Local Anesthetics. — Argyrol, cocain, novocain, and all 
similar drugs for eye and ear work or local anesthesia 
are prepared in most attractive and useful form by cer- 
tain firms so as to be handled quickly and accurately, 
though nothing can be made fool-proof. The varied 
opinions about how long certain solutions are good render 
the tablet method the safest. 

Cocain comes under the Harrison law in New York 
State, and the operating room must keep an accurate 
account of all it uses, just the same as any ward or any 
private physician. 

These drugs must not be heated. Heat destroys cer- 
tain properties or develops new ones, making them harm- 
ful to the patient. They are so carefully handled in the 
wholesale laboratories which are strictly conformed to 
the laws of hygiene that they need no sterilization. 

One Per Cent. Solutions. — It is said that 4f grains to 
the ounce, to be accurate, or 5 grains to the ounce, roughly 
speaking, makes a 1 per cent, solution. Why is this? 
The nurses must know their tables of dry and liquid 
measure and work out on paper all percentage problems, 
to be shown to a supervisor. Arithmetic in its eighth 
grade forms should be made a rigid test for all nurses be- 
fore admitting them to training. 1 ounce = 8 drams; 
1 dram = 60 grains; 1 ounce = 8 X 60 grains = 480 



FORMULA AND DIRECTIONS 143 

grains. Roughly calculated, we call 1 ounce 500 grains. 
1 per cent, means 1 per hundred, or to~o. Too of 480 
grains = 4f grains. 

Certain eye solutions are effective in the strength of 
1 per cent., and from tablets marked so many grains we 
should make up the solution with distilled water in a 
sterile basin. 

In making up solutions, find out how much is going to 
be used. Much extravagance is shown with drugs by 
making too large an amount of solution. This must be 
checked, so that nurses may not waste money in private 
families by foolishly ordering too much of any drug. 
Nurses should not dispense. It shakes the confidence of 
physicians and patients to see nurses with doubtful 
arithmetical ability working in the drug room. 

The difference of \ grain (5 — 4-f) makes a tremendous 
difference in the effect of some drugs, especially w T hen a 
fairly large solution or a frequent use is desired. Pharma- 
cists must never use the extra fifth. Their weights and 
measures are always uniform, and accurate. 

Rubber Tissue (Gutta-percha Tissue). — To cleanse and 
sterilize lay on a cold glass table, scrub with small brush, 
using tincture of green soap and cold water on each side, 
rinse under cold water tap, soak over night in bichlorid of 
mercury 1 : 500. Next day lift with sterile forceps into 
a sterile basin of water, then fold in dry sterile towels 
until dry, afterward sterilize in the dressing sterilizer for 
twenty minutes at 15 pounds' pressure, laying gauze 
strips between every two layers of tissue. Use a double 
muslin dressing cover. This is used mostly for cigarette 
drains. It does not stand frequent sterilization. The 
supply must not be allowed to get friable, since it is called 
for at critical junctures. A successful nurse is she who 
frequently goes over her whole stock of goods to see its 
condition. The date of sterilization for each gives an in- 
dication of its state. Rubber tissue should be put up 
without pins, merely folded deeply so as to stay closed. 
Mucilaged labels are very convenient and inexpensive 



144 OPERATING ROOM 

for such dressings. Flour paste is cheap and useful for 
labels, made by dissolving a teaspoonful of flour in one 
cup of cold water and boiling until clear. 

Rubber Gloves. — Gloves must first be washed in cold 
water to remove K-Y, vaselin or blood; second, all the air 
squeezed out so that they stay under water, then wrapped 
in old muslin so as not to stick to the sides of the boiler 
above the water line, dropped into the boiler, and boiled 
for five minutes. The sterilizing room must have its 
own clock, on the wall behind the sterilizers, in plain view 
while they are being run. The gloves are lifted out, 
drained, tested for holes with cold water, and hung on the 
glove-tree to dry. The hospital carpenter can make a 
glove-tree, like a hat-tree, a pole on a tripod with prongs 
of wood the size of a clothes-pin and as nearly vertical as 
possible, on which the glove hangs by one finger. When 
dried on one side they are almost dry on the other, but 
are turned. Then they are sent to the workroom in two 
lots, those with holes and those without, to be mended 
with "pure gold" rubber cement. The holes are located 
by blowing up the glove and listening for the escape of 
air, w T etting it slightly in a doubtful place to look for 
bubbles (Fig. 19). To blow up a glove, hold it taut by 
both sides of the wrist with forefingers and thumbs, twirl- 
ing it over, and catching it all in at the wrist, pushing the 
air up into the digits. To mend, roughen the area around 
the hole with sandpaper or a naij file, cut the patch with 
round edge, apply and press firmly for a few moments with 
the warm hand, then lay in a press. Powdery gloves do 
not take the cement. If any portion of the glove dilates 
too much, mark it "poor" and keep in a class by itself. 
To powder the gloves, shake a large quantity of unper- 
fumed talc powder in a gallon basin set on the work 
table, and station yourself on a high stool so as to have 
purchase when pressing downward, then pass the gloves, 
both sides, through the powder, squeezing them down on 
the unyielding basin. Fold the cuffs back until they only 
are wrist length (short), so that the scrubbed hands of the 



FORMULA AND DIRECTIONS 



145 



surgeon, none too clean at best, surgically speaking, do 
not touch the outside when putting them on. Match 
the gloves for hands and sizes, then lay in their cases and 
envelopes, marked as to size, condition, whether perfect, 




Fig. 19. — Detecting holes in a glove. 



poor, or mended, and for any special surgeon, and "dry 
sterilize" for twenty minutes at 15 pounds. 

One method of packing gloves for sterilizing includes 
in one dressing cover the glove cases for the chief operator 

10 



146 OPERATING ROOM 

and his assistants. Another method is to put each glove 
case (one pair) in its own envelope, so that it may do for 
anyone who wears that size. The scrubbed nurse's gloves 
are done up for her separately. If many are put up in 
one bundle, and the chief's, for instance, are imperfect, 
a whole new set must be unsterilized. When a new opera- 
tor or intern comes the nurses should at once register the 
exact size he wears, and it is very flattering to a surgeon to 
have the proper size handed to him, wet or dry, three 
months later when he again visits a new hospital. He 
will show his appreciation. To prevent inaccuracy 
about gloves the nurse who mends them should put them 
in covers and leave a signed slip inside each case. Put 
a small envelope of powder in with each pair of gloves. 

Rubber Tubing. — This must be suited to the various 
wounds in length, lumen and firmness, or thickness of 
wall. Some pieces will be cut into a T and reversed in 
direction, therefore requiring a greater length. There 
must be a whole range of sizes in diameter, pliability, and 
length. If the surgeons at any time let drop a hint of 
what they may some day in the future want for special 
cases it is easy to keep it in stock. There should be no 
anxiety about it in the surgeon's mind. Rubber does not 
keep well after three months. Do not buy any with a 
disagreeable odor, made from old goloshes and auto- 
mobile tires. Buy it as pure as possible, considering the 
firmness. When in reserve stock, unprepared, rubber 
should be in a cold place, dusted with lycopodium, which 
is blown out before washing and boiling. By wrapping 
all rubber in old muslin no scum from the water can col- 
lect on it in hard masses. Boil for ten minutes, then 
transfer with clean forceps into a clean boiled jar con- 
taining carbolic acid solution (5 per cent.). Do not cut a 
catheter to get a fine drainage-tube. Have the finest 
tubing as well as the largest. 

Catheters, Filiforms, and Bougies. — These are kept 
until used in a cold place in lycopodium powder. There 
should be made by the hospital carpenter a large flat box 



FORMULA AND DIRECTIONS 147 

with lid and padlock, divided into compartments -for each, 
so as to help in instantaneous selection or to review the 
stock as to number of each size. The nurse who has the 
care of these goods must be informed when one is taken 
out to be lent or used for some special purpose, A 
spindle in the workroom on the table (protected by a 
cork), or a bill-file high on the wall, will prove a good way 
to keep all such memoranda — "Retention catheter 
(mushroom), No. 14, sent to Ward B for Mrs. Mintz." 

Rubber catheters should be washed in cold water with 
soap to remove any lubricant, then held under the cold 
tap and milked, as a cow's udder, to remove any solid 
particles inside, then boiled in old muslin, and hung up 
in a cool place to drain. Catheters must always be 
stretched to show if they have lost their resiliency. A 
catheter which is roughened or has any cuts or slashes 
around the eye must not be used. Catheters (rubber) for 
men and women should not be taken from the same 
place. To avoid this, use a female rubber catheter, 
8 inches in length, made by at least one great hospital 
supply firm. The short length prevents its touching any 
unscrubbed part. The long male catheters get twisted 
and drop. 

Silk catheters must not be boiled, bent, or carbolized. 
They are of woven silk, covered with shellac, and must 
be kept cool at all times. They are harmful to the 
urethral canal if roughened the slightest bit by causing 
abrasions and stricture. They must be washed with 
cold water and a mild soap, such as Castile or Ivory. 
All soap ends may be boiled down into a fluid paste for 
such purposes. The silk catheters are then drained, and 
may be hung in a small fumigating cabinet to dry. Such 
a cabinet, suitable for electric non-boilable apparatus, 
should be improvised at small cost; a box with a door 
sealed with "gumtite" or other gummed paper which, 
when the articles are required, can be turned with its 
door to the open window to drive off the fumes of for- 
maldehyd from the candles used on the last occasion. 



148 OPERATING ROOM 

Fine cabinets for this purpose are made by the hospital 
supply companies. 

F iliforms are treated like silk catheters. A carbolic 
solution which would disinfect would ruin their texture. 
Some filiforms are olive-tipped — some are as fine as a 
horsehair. 

Bougies are solid catheters of waxed silk or catgut, 
chemically treated so as to be firm enough to create a 
passage or locate a stricture in the urethra. 

Retention catheters are to be retained in the bladder, and 
are inserted from above in the course of the operation, 
or inserted at its conclusion, while the patient is yet 
relaxed, by means of an olive-pointed bougie or a large 
uterine probe. No force is employed, but much lubri- 
cant. Very slender uterine dressing-forceps have been 
used, but it is risky on account of- the numerous folds of 
mucous membrane in the urethra, and only when the 
patient is under an anesthetic. 

Preservation of Specimens. — When a section is cut 
out of a growth to be "frozen" and examined imme- 
diately before proceeding with the operation there is no 
time to waste in long journeys to a distant laboratory. 
Everything must be ready in the workroom, including the 
microscope: (1) A watery solution of formalin, 5 per cent., 
three to five minutes' immersion; (2) 50 per cent, alco- 
hol, three minutes; (3) absolute alcohol, one minute; 
(4) wash off with water, stain, etc. 

This is a speedy "combination freezing and fixation" 
method by Dr. Thomas Cullen of the Johns Hopkins 
Hospital. It is the nurse's duty to provide the stock mate- 
rials and utensils, graduates of all sizes marked in the 
metric system, and a place where the pathologist has 
suitable light for his work. 

Black Rubber Hard Goods. — These must be kept in 
cotton-lined boxes, so as not to chip or break. If rough- 
ened they would destroy the part where they are placed. 
They are cleansed by cold water, soap, bottle or tube 
brushes, and carbolic acid, 5 per cent. Black hard 



FORMULA AND DIRECTIONS 



149 



rubber must not be boiled, or the shape, as of a trache- 
otomy tube, is ruined. 

Silver Leaf. — This is bought in books, of silver in- 
terleaved with paper (Fig. 20). This book should be 
cut into sections, each containing five sheets of silver. 
Each booklet is then protected by two sheets of heavy 
cardboard, the whole being wrapped in a double muslin 
cover, pinned, and marked for sterilization for twenty min- 
utes at 15 pounds. In a general way, all clean articles, 
such as silver leaf, which cannot be boiled and are not used 





HALSTEDS 

SILVER 
FOIL 



Fig. 20.— Silver foil. 



again, are sterilized for twenty minutes at 15 pounds. It 
is a very lazy method to keep all the silver in one book, 
and, besides, it causes exposure to the infection from in- 
struments used in a wound. 

Care of Instruments. — After operations count each 
kind and classify into (1) Needles — straight, curved, etc.; 
(2) knives; (3) scissors; (4) blunt instruments. 

Collect in separate basins, and if one is missing, get it — 
if the patient has to be reopened — immediately. Wash in 
cold water and prepare to boil as follows: (1) Fasten the 
needles in gauze with two bites each; (2) fold the knives 



150 OPERATING ROOM 

and scissors into old muslin, each in a layer by itself; 
(3) drop in the blunt instruments; (4) drop in the sharp- 
edged instruments according to the house rules of the 
Medical Board, or place in carbolic acid, then pure alco- 
hol, for the time required; (5) add a handful of vmshing 
soda (sodium carbonate) when boiling instruments (a) to 
soften the water; (b) to raise the temperature and facilitate 
sterilization; (c) to prevent rust. 

When boiled, lift out on the tray, drain, and prepare 
to polish. Use a thick pine board, 1| by 1 ft. by 1 in., 
having a headpiece to work against and a place for 
brushes and Bon Ami. Superannuated tooth- and nail- 
brushes, well-boiled flat wide corks, pieces of gauze and 
flannelette are best for instruments in getting at the 
crevices and corrugations. This is the time to see whether 
they need renickelling. Wash off thoroughly in a lathery 
solution of tincture of green soap and at once transfer to 
a basin of alcohol. A pint of alcohol may be used over 
and over again in this way, being at other times tightly 
corked and definitely labelled. The corrugations, joints, 
and locks are w T ell lubricated with vaselin after the in- 
struments are thoroughly dried. Needles are threaded 
with suitable silk and run in flannel, scissors and other 
instruments laid systematically on the shelves, and 
knives laid in their boxes. Calcium chlorid in the 
cabinet absorbs moisture and camphor prevents oxy- 
genation of the silver probes and catheters. 

How to Care for Rubber Utensils (Soft). — Rubber 
aprons are soaked in bichloricl of mercury (1 : 1000) 
before operation. After operation they are scrubbed with 
cold water, brown soap, and a brush, rinsed with plain 
water, and painted with carbolic acid solution, 5 per cent., 
then dried over a bar and powdered. All flat rubber 
should be rolled on a roller under the edge of a counter or 
shelf; the roller of a w T indow-shade can be adjusted for 
this. Rubber douche bags, seldom used now, can be boiled, 
and after using hung upside down to drain. 

How to Prepare Sterile Adhesive. — Cut the strips the 



FORMULAE AND DIRECTIONS 151 

desired length and width, roll on a wide-mouthed bottle 
(single thickness), and sterilize in the dressing sterilizer 
in a double muslin cover. When needed they may be 
easily loosened by pouring hot sterile water in the 
bottle, beginning first by tempering it with a little cold 
water. 

To obtain a fine line of union without the possibility of 
stitch abscesses certain surgeons use adhesive edged with 
hooks and eyes. Sew the hooks and eyes on two strips of 
white 1-inch tape at the proper distances for a length of 
8, 10, or 12 inches, to be slightly longer than the char- 
acteristic incision made by your surgeon. Cut sheets of 
adhesive the same length and 6 inches wide. Leave the 
crinoline on all but one side, where it is removed at a dis- 
tance of 1 inch. Plaster the hooks and eyes on, tape down, 
into position, slightly turning in the edge of the adhesive. 
Face the bare inch surfaces with adhesive, its edge also 
turned in a little. Overcast the edge clown among the 
hooks or eyes. Then remove the crinoline and plaster the 
two sheets side by side on a large brown gallon bottle. 
Do up in a double muslin cover and sterilize as above. 

Ivory-handled Eye Knives. — These must not be 
boiled. They may be disinfected in benzine or formalin 
and rinsed, then wiped dry. 

Needles with a Lumen or Bore. — All hollow needles for 
aspirating or hypodermic use, after being boiled, should 
be held in forceps over an alcohol flame. This dries with- 
out discoloration. Then insert the dry oiled stylet. 
Never put away a needle or trocar without its stylet. 

Glass Syringes. — Ground-glass syringes are sterilized 
by boiling in separate parts. After they are boiled and 
cooled and wet again, insert the plunger in the barrel. 
They must be thoroughly washed before boiling. 

Tracheotomy Tubes. — When a tracheotomy tube is 
in situ it is best cleaned by pheasants' feathers, which 
are firm yet flexible and pointed. They should always be 
on hand. The whole apparatus is covered with gauze 
moistened in soda bicarbonate solution. 



152 OPERATING ROOM 

Hospital Cold Cream. — For the anesthetic room some 
cream is needed for patients who fear the use of vaselin, 
etc.: 

White wax Sjv. 

Spermaceti §iv. 

Liquid petroleum (white mineral oil) Sxxxij. 

Sodii borate (borax) §ss. 

Rosewater §xvj. 

Melt the wax, spermaceti, and oil together at a very moderate 
heat. Dissolve the borax in the rosewater, then warm this solution 
and add it to the melted waxes and oil, and stir briskly until cool and 
creamy. 

Hospital Hand Lotion. — 

Powdered tragacanth oj- 

Alcohol 5 ss. 

Mix together and quickly add 1 pint of water and stir briskly. 

Add 1 ounce of glycerin and 2 ounces of alcohol and add water to 
make 1 quart. 

Perfume to suit. 

To Sterilize Vaselin. — Sterile vaselin is prepared by 
setting the container in a water-bath and putting a 
dairy thermometer in the vaselin, raising it to 212° F., 
and keeping it at that point for an hour. The lid is boiled 
beside, but not on, the container. To obtain sterile vaselin 
from such a jar afterward dip in a sterile grooved direc- 
tor that has not been included on the instrument table. 
Do not put in the gloved finger. The grooved director 
may be then drawn over a sterile compress or applied to 
the glove. One can judge by the surface being intact 
that the vaselin is sterile This should be done daily in 
cases of constant catheterization, etc. 



CHAPTER XI 
THE METRIC SYSTEM. SOME BRIEF NOTES 

LENGTH 

The basis of the metric system is the unit of length. 
From it are worked out the units of the second and third 
dimensions, and of capacity and weight, by combining 
certain facts in physics, relating to temperature, or density 
at certain times. In order to have a distance that would 
be international and non-disputable, when changing their 
system of measures the French took for a unit that 
measure which is one ten-millionth of the distance between 
the equator and the North Pole, or 39.37 inches, a little 
longer than 1 yard, and called it a meter. 

To get smaller units of length (one dimension) they 
divided the meter into 10, 100, etc., equal parts, using 
Latin prefixes to denote diminution: 

Meter = 39.37 inches (more than 1 yard). 

Decimeter = 3.937 inches (about | foot). 
Centimeter = .3937 inch (cm. = about f inch). 
Millimeter = .03937 inch (mm. = about -^ inch). 

To get larger units of length they increased the meter 
to 10, 100, etc., times its length, using Greek prefixes to 
denote multiplication : 

Meter = 39.37 inches. 

Decameter = 393.7 inches. 
Hectometer = 3937 inches. 
Kilometer = 39370 inches (about f mile). 

SQUARE MEASURE 

Square measure is derived from this unit of length, the 
meter, since we multiply length by length to get area. 
If a plot of ground is 5 meters long and 4 meters wide it 
contains 5 X 4 = 20 square meters. 

153 



154 OPERATING ROOM 



CUBIC MEASURE 



Cubic measure for wood, loads of earth, etc., is also 
derived from this unit of length, the meter, since we 
multiply length by breadth by thickness (all being 
distances in meters, etc.) to get volume of earth and other 
materials for building, etc. 

If a load of earth is 16 decimeters long (16 X \ foot = 
4 feet) by 12 decimeters wide (12 X \ foot = 3 feet) by 
8 decimeters deep (8 X \ foot = 2 feet), the whole load 
then contains 16 X 12 X 8 = 1536 cubic decimeters, or 
4 feet X 3 feet X 2 feet = 24 cubic feet. 

If 1 decimeter of length = about \ foot, then 1 cubic 
decimeter = \ foot length X \ foot breadth X \ foot 
depth (or thickness) = fa cubic foot, -ff- = 24 cubic 
feet. 

VOLUME 

Volume is the measure for water and many other mate- 
rials requiring a different kind of utensil. A cubic centi- 
meter is a mass of water that has the following propor- 
tions : 

Length 1 centimeter (.3937 inch, or about f). 

Width 1 centimeter (.3937 inch, or about f). 

Thickness. .... 1 centimeter (.3937 inch, or about f). 

A cubic centimeter has three dimensions and is the same 
size in every direction, appearing as follows, 



only greatly reduced, since each side would be only f inch 
long. 

The cubic centimeter has been taken as the unit or 
starting-point for measuring fluids, such as normal saline, 
blood, etc. 



THE METRIC SYSTEM. SOME BRIEF NOTES 155 

There are 1000 cubic centimeters in 1 quart, which 
corresponds to the French liter. 

There are 500 cubic centimeters in 1 pint. 

One pint = 16 ounces = 128 drams = 7680 minims, 

5T0 of 7680 = about 15 minims. 

One cubic centimeter = 15 minims approximately. 

WEIGHT 

In order to get a unit of weight the mathematicians 
then took 1 cubic centimeter of distilled water at 4° C, 
its thickest or densest period, and calling its weight 
(15 grains) 1 gram, made that the standard or starting- 
point for all substances that are weighed. They used 
the same Latin prefixes to denote diminution. 

1 gram =15 grains Troy, dry weight. 

1 decigram = 1.5 grains Troy, dry weight, or 1J grs. 

1 centigram = .15 grain Troy, dry weight, or o 3 gr. 

1 milligram = .015 grain Troy, dry weight, or of gr. 

To denote increase or multiplication of weight Greek 
prefixes were used: 

Decagram = 150 grains Troy, dry weight, about -£$ oz. 
Hectogram = 1,500 grains Troy, dry weight, about 3 J oz. 
Kilogram = 15,000 grains Troy, dry weight, about 2 lbs. 

1 pound =16 ounces = 128 drams = 7680 grains. 

2 pounds = 7680 X 2 = 15,360 grains. 

15,360 1 R . . + _ 

100n grs. =15 grains approximately. 

It is not absolutely true of all drugs, but approximately 
speaking, minims (wet) weigh as much a3 grains (dry), 
and that is the cause of the coincidence in the 15. 

Substances Measured in 

Minims. Grains. 

Saline. Powders. 

Oils. Salt. 

Blood. Silver nitrate (solid). 

Tincture of iodin. Argyrol (dry, solid), etc. 

Tincture of digitalis, etc. 



156 OPERATING ROOM 

It may be of interest to note that the original meter is 
the distance between two lines on an actual platinum- 
iridium rod preserved in the archives of the International 
Metric Commission at Paris. Many European countries 
have adopted the metric system, thus facilitating all forms 
of international relations, but it is especially suited to the 
scientists, who thus have one common and delightfully 
systematic medium of communication. 



CHAPTER XII 

SPECIAL DRESSINGS 

Mastoid Tips. — Gauze comes in 100-yard pieces in 
folds 1 yard square. In cutting dressings it is most 
economic to cut this large fold in the center, and then 
pick up each and open it out for 1-yard squares fluffed. 
But for small dressings, where we wish to keep the whole 
pile flat, layer upon layer for at least twenty thicknesses, 
we cut off the folded edges (ten) very sparingly, keeping 
the pieces to fill pads for perineal wear. Then the large 
square is cut in sixteen equal parts, four to each side. 
These small squares are now laid all on one pile and made 
into tips in the following manner: 

(1) Pull one piece off the pile with the left hand. 

(2) Catch it by the right forefinger and thumb in the 
very center and pull it through the left hand, which is 
closed over it. 

(3) Lay it to the right in a pile, with the nose pointing 
away and the ragged ends nearer. 

(4) When about a thousand are made, pick them up 
with the right hand, place the noses in an even row or 
cluster, turn, and trim off the ragged ends with one cut of 
large bandage scissors, leaving the tips 6 inches long. 

(5) Put up in double muslin covers in bundles of thirty 
or so. 

Mastoid Dressing. — Arrange for sterilization in the 
double muslin square covers and put in as follows: 

(1) A square of blue tissue off cotton to keep fluff off 
the cover. 

(2) A square of cotton 6 inches each way for an adult, 
then blue tissue, then another- square of cotton. 

(3) A piece of plain gauze packing, 9 inches long and 
\ inch wide (being perfectly sterile, not on the table). 

157 



158 OPERATING ROOM 

(4) A gauze roller bandage of the finest quality, 2 
inches, the sizing sets it when wet a little on the outside. 

Gant Pad. — Used for hemorrhoidectomy or prolapsed 
rectum. Make the usual flat folded compresses, each 
one-fourth of the large gauze square yard. With all the 
raw edges turned in, these are 4^ inches square, as meas- 
ured up to the patterns cut or lined on the work-table. 
Take two compresses and cut each in half. Turning in 
that raw edge, fold the first half-piece in four equal layers, 
the second in five, the third in six. Roll the fourth in a 
tight, hard roll, keeping tight with a safety-pin tempo- 
rarily in the center. Lay them in a pile one above the 
other, making a sort of pyramid or wedge. With two 
strips of adhesive, each 6 inches long and \ inch wide, 
wind the tw T o ends of the pile tightly. This causes the 
bottom layer to lie flat and each one above it to bulge. 
When the whole is laid with its convex side against the 
anus, the flat side being pressed in by a binder, the bulg- 
ing edge is made still more convex. By being well lubri- 
cated it forms a good dressing for a prolapsed rectum, 
being held in place with stout adhesive straps from but- 
tock to buttock. 

"Whistle," or Tampon Canula. — This prevents oozing 
of blood by pressure after hemorrhoidectomy, permits 
any considerable hemorrhage to show itself in the outer 
dressings, the painless escape of flatus, or introduction of 
enemata. Take a piece of stiff rubber tubing 3 inches 
long, smear with sterile vaselin, and wrap around with 
plain gauze, vaselin being rubbed into every turn of the 
cloth. Wind the gauze spirally at what will be the intro- 
duced or proximal end, so that it presents the form of a 
truncated cone. Slip a large safet}-pin through the distal 
end so that it cannot entirely enter the rectum. Follow 
with split gauze compress pad and T-binder. 

"Canule a Chemise" (Petticoated Tube). — The gauze is 
gathered about the end of a piece of rubber tubing, just 
like the cloth of an umbrella at the ferrule of an umbrella, 
hanging down from it loosely like the unbound umbrella. 



SPECIAL DRESSINGS 159 

The tight end is introduced into the rectum, the loose 
part acting as a drain or a fluffy pressure pad, all being 
well smeared with sterile vaselin. 

Leg Rolls. — The selvedge must be cat off so as to pro- 
duce a softly yielding spiral when applied. Cut off in 
one piece three thicknesses of the yard-square gauze. 
Fold over so that the selvedges come together and trim 
them off very sparingly, then cut in two, down the central 
fold, making thus two pieces \ yard wide and 3 yards long. 
Open out, turn the ends in about 2 inches, fold almost to 
the center, and fold over, making a strip 4| inches wide. 
Hold squarely on a solid table and roll very evenly. 
Do up in packages of two. 

Tampons. — Required, lambs' wool or best grade of cot- 
ton, smooth stout cotton cord (knitting cotton No. 4), 
and the medications desired. Cut the cotton or wool in 
squares \\ inches each way. Roll fairly snug and throw 
twice around the center or waist a doubled twine, work- 
ing with the folded end of it. Pass the loose ends through 
the noose and tighten, then steep in the medication or- 
dered. For a very young woman tampons may be made as 
follows: Cotton 1 inch square and only about \ inch thick, 
wind with noose around the center, bring the ends to- 
gether at the right and left to cover the cord, and trim 
until perfectly round and even, like balls of wool in fancy 
w T ork used as round tassels. If not medicated, tampons 
should be lubricated. 

Small Sponges. — The Best Way. — Cut the gauze in 
9-inch squares by first trimming off the edges of the flat 
yard folds; second, cutting each side into four equal 
parts, sixteen to the whole square yard. Having all these 
9-inch squares in one pile squarely in front of one, place 
the upper left-hand corner down on the lower right-hand 
corner, making a triangle. Place the left hand in anatomic 
position, palm upward, on the gauze and, enclosing the 
first three fingers in it, bring the two long points (of the 
fold) and the third remaining point down into the palm 
in a line with the fold in one big soft but secure twist. 
Secure it with the thumb and gently turn inside out. 



160 OPERATING ROOM 

Cloth Retractors. — These are intended to hold the soft 
parts out of the way during an amputation while the 
bone is actually sawed. A piece of stout unbleached 
muslin, 2 feet long and 1 foot wide, is torn lengthwise 
half-way into two or three tails, put up in a double cover, 
and sterilized. Two tails are proper for the humerus or 
femur, three tails (leaving the middle narrow tail for the 
interosseous space) in the forearm or leg (each of which 
has two bones). 

Bandaging. — Every nurse should be able to apply any 
bandage with the edges turned in and to be handy with 
needle and thread when stitching it in position. 

Making Packing. — Use the best gauze bandages. 
Sit with the right foot on a low stool. Turn in the end of 
the bandage, then turn each edge in toward the center. 
Then fold the two folds together so as to make the final 
strip one-quarter the original width. Roll the first few 
inches with both hands into a tape-like roll. Then pin 
securely as much as is finished. Then, holding the raw 
bandage in the left and the finished roll in the right, turn 
the edges in to the center, and again, together with a 
sawing motion over the knee, aided by the fingers of the 
left and applying traction with the right. Pin securely, 
after rolling up with the right steadily, every few inches. 
Two pins will do, alternating like cribbage pegs. 

Eye Pads. — To prevent ether eyes cut a piece of gauze 
8 inches square. Fold it on itself laterally. Leaving a 
space of | inch in the center, bounded by vertical stitching, 
pad it to fill in the hollows of the eyes and nose, so that 
when it is laid on the face the eyes will be protected 
from any random drops. 

Aristol Pledgets. — Take a very thin shred of the finest 
absorbent cotton and pick it until it is a circle f inch in 
diameter, then gather all the edges in to the center and 
lay it on a smooth glass slab, rolling it with the ends of 
the second and third fingers, the palm facing downward, 
and, as when playing the piano, perfectly horizontal. 
With practice these can be rolled, like the opium-smoker's 



SPECIAL DRESSINGS 161 

"pills," into perfect balls. When a large number of this 
and gradually smaller sizes are rolled they are then stirred 
about in a square glass basin containing a couple of drams 
of aristol until they carry all they can. They are then 
sterilized in a jar. 

Applicators. — (The soiled cotto'n on any applicator 
must always be removed by a bit of fresh cotton. Note!) 
The applicators must be rolled so that the part used can 
be easily removed. Take a thin shred of cotton about 
1 inch square, of an even thickness, and, laying the end 
of a long (6-inch) double ear applicator (wooden) in the 
center of it roll the cotton trumpet shaped, fastening it 
with moderate firmness at the base. Wind both ends of 
wooden applicators, place in glass tubes (open at both 
ends), cover, and sterilize. With toothpick applicators 
the ends are so weak that about § inch must always be 
broken off smoothly lest it break in the patient. The 
best toothpicks are of pine or cedar and are rather rough 
and square in the thickest part of their body; not the 
polished, rounded, fashionable cafe toothpick. The 
rougher surface holds the cotton. Take a very thin 
shred of finest absorbent, pick it to a square, fold it like 
a diaper once, then lay the point of the toothpick in the 
middle of it and roll, finishing by running the thumb-nail 
around the base. Then, to make it pretty and smooth, 
revolve it with the right hand, holding the cotton head 
between the tips of the thumb and second finger of the 
left hand, pressing down from above gently with the tip 
of the forefinger to polish and bevel it into the shape of a 
trumpet. These are thrown away after using, and being 
inserted into infants' ears or nostrils, the cotton must not 
come off. 

Tape Stickers. — These must be made according to the 
drainage cases. For a back, use a piece of basswood splint, 
9 inches long and 3 inches wide. Use the adhesive rolls; 
the cheaper way to buy it and suited to all purposes. 
Nick the end of the roll in 3-inch widths ready to tear, 
and tear the strips one at a time, cutting them off below. 
11 



162 OPERATING ROOM 

Then carefully strip off the crinoline, of which part is to 
be used again. At one end fold down one corner squarely 
on itself, a little past the center (about If inches), then 
the other corner on top of it, making an even edge where 
they meet. This overlapping made by folding past the 
center gives three thicknesses to cut through for the tape. 
Now fold this point on itself, and in the center make a 
V-shaped nick all the way through. Then lay the strip 
on the basswood splint, gummy side to the wood, so that 
the ends are flush and they adhere for 4 inches. Fold back 
on itself and apply the crinoline to the remaining space 
as far as the double tip. Take now 9-inch lengths of 
^-inch white tape, make a nick or opening 1 inch from 
the end, running not crosswise, but with the length of the 
tape, slip the short end through the hole in the adhesive, 
then thread its long end through its own eye. Make a 
number, adhering thus in the first 4 inches of their length, 
crinolined in the center, folded, and threaded with tape, 
six to a splint. 

How to make a T-binder in a hurry from a bandage of 
muslin: Cut off 1 yard of a 3-inch muslin bandage. Fold 
it crosswise by its length and slit it for | inch, the cut 
running lengthwise with the cloth. Take a second piece 
1 yard long and 3 inches from the end, fold it over length- 
wise, slitting it crosswise for 1 inch. Thread this short bit 
through the cut in the middle of the w r aistband, the first, 
then thread the long remaining stem of the T (which goes 
between the thighs) through its own eye. For a male 
patient split this latter for § yard up from the other end, 
the bottom of the T, to secure the dressings. This saves 
safety-pins. 

Whether the supplies are made by probationers in a big 
supply-room or by the nurses of the operating room, they 
must be supervised by the head nurse of the operating 
room. This unifies the work of the house, and, in any 
event, the pupil finishing her operating-room service 
should know all there is to be known about making 
dressings. 



CHAPTER XIII 

TERMS USED IN SURGICAL DIAGNOSIS 

The pupil is humanely curious about the cause for 
bringing each patient under the knife, and we should 
use, not neglect, to our own great advantage this most 
potent agent, indeed, for inducing many to "sign up" 
for three years' training, to get an insight into, not 
anatomy, but pathology, in which oddly enough no 
primer has been written yet for nurse training-schools. 
The pupil is entitled to know the diagnosis, if that has 
already been explicity made, before she attempts to "set 
up" for the operation. When it is all over, and the pa- 
tient is ready for the ward, the unscrubbed nurse draws 
up a slip, attached to his chart temporarily, on which are 
blanks for the diagnosis, operation, stimulation, etc. 
(See chapter on Nomenclature.) She must, therefore, 
be familiar with the sound and the meaning of the terms 
required, so as to transmit them properly to her co- 
workers on the wards and so as to enable all to carry on 
their work more intelligently and happily. In the tense 
moments between two cases it is maddening for the 
supervisor to hear a dazed, "I beg your pardon. What 
did you say the diagnosis was?" or "How do you spell 
that?" But, again, it is very easy to peep at a text-book 
nearby in a moment's pause to look up a term one has 
just heard fall from the surgeon's lips, the image of the 
thing discussed now engraved forever on one's mind be- 
cause the specimen is "right there" for observation. So 
closely are these terms of diagnosis connected with the 
minor outlying conditions that accompany the central 
disturbance, with the names of measures employed to 
remedy them, and with the specific term for the specific 

163 



164 OPERATING ROOM 

operation, that the following list of definitions does not 
try to separate the three classes. All may be heard in one 
conversation and in a simple work of this kind it would 
be foolish to draw up a third dictionary, since it causes 
too much hurried fumbling. There are in the following 
text no terms not commonly used, but it is attempted to 
give a comprehensive list of all that will be used relating, 
not to what is done in the operating room (see chapter on 
Nomenclature), but relating to the conditions preceding 
and necessitating the operation. 

Pathologic tissue means diseased tissue, in this in- 
stance to be treated surgically. It may be diseased by in- 
flammation, benign or malignant tumors, cysts of a watery 
or purulent nature, malformations, transformations, con- 
genital absences of parts and other deformities, besides 
those resulting from accidents and wounds. All terms 
ending in itis denote inflammation of the part named, as 
cholecystitis, inflammation of the gall-bladder. 

TABLE OF TUMORS 

Normal tissue. Tumors found therein. 

Fibrillar connective tissue. ............... .Fibroma singular, 

fibromata plural. 
Greek nouns ending 
in oma form plural 
by adding ta. 

Mucous tissue ........................ Myxoma. 

Embryonic connective tissue. ............ .Sarcoma. 

Endothelial tissue. Endothelioma. 

Fat tissue . Lipoma. 

Cartilage Chondroma. 

Bone. .................................. Osteoma. 

Neuroglia. ............. Glioma. 

Muscle tissue type. Myoma. 

Smooth muscle tissue. Leiomyoma. 

Striated muscle tissue. Rhabdomyoma. 

Nerve tissue Neuroma. 

Vascular tissue (veins and arteries) ......... Angioma. 

Lymph vessels. .- Lymphangioma. 

Glands Adenoma. 

Various forms of epithelial cells and asso- 
ciated tissues. Carcinoma. 



TERMS USED IN SURGICAL DIAGNOSIS 165 

CYSTS 

Cysts are sacs filled with watery, purulent, or cheesy 
material, and are of two kinds: (I) Those developed from 
pre-existing cavities. (II) Those originating independ- 
ently after pathologic changes. 

Class I is formed by an accumulation in a gland or its 
excretory ducts of secretion (altered somewhat) when 
pressure or inflammation hinders normal discharges. 
This secretion is either mucous, sebaceous, or serous. 
To these belong the comedone, milium, ranula, chalazion, 
atheroma, milk cyst, ovarian cyst, cysts of fallopian 
tubes, of gall-ducts, the transudation cysts due to 
chronic inflammation in the lymph-spaces or serous 
sacs — namely, ganglia, hydrocele, and hematocele. 

Class II is formed (1) by the softening and disintegra- 
tion of tissue (e. g., from old abscesses); (2) or by the for- 
mation of a wall around foreign bodies (parasites, masses of 
blood producing an inflammation and becoming encapsu- 
lated); (3) or by new growths in whose spaces various 
kinds of fluid accumulate, quite like glands, as adenomata 
on the ovaries, though they are called cystomata; (4) or 
congenital cysts, dermoid cysts of the ovary or of sub- 
cutaneous tissue (as the scalp), being probably part of 
another fetus. 

GLOSSARY OF TERMS 



Abortion. Expulsion of the contents of the pregnant 
uterus before the child is viable (end of sixth month). 

(1) Abdominal. Escape of fertilized ovum into peri- 
toneal cavity, where it attaches itself to the intestine. 

(2) Complete. The sac comes away intact. 

(3) Criminal. Procured artificially without being 
necessary from the legal standpoint of -the patient's 
health. 

(4) Epidemic. Arising from the presence of conta- 
gious disease. 



166 OPERATING ROOM 

(5) Habitual. Repeated, due to syphilis usually. 

(6) Incomplete. When the membrane or placenta is 
retained. 

(7) Inevitable. When the sac has ruptured and the 
fetus is about to appear. 

(8) Septic. When the patient becomes infected 
through the introduction of bacteria or the decay of re- 
tained tissue. 

(9) Spontaneous. Not induced by artificial means. 

(10) Therapeutic. Induced to save the mother's life. 

(11) Threatened. Appearance of symptoms which 
are checked by putting the patient to bed and giving her 
opiates. This usually can check an honest miscarriage in 
the early symptoms. 

Abscess. A localized collection of pus surrounded by 
a wall of leukocytes. 

Cold Abscess. Tuberculous, usually about a bone, 
joint, or gland — slight pain, no acute inflammation, very 
slow. 

Psoas Abscess. Both cold and psoas are misnomers, 
generally low Pott's disease; pus from the spine runs along 
the psoas muscle pointing beneath Poupart's ligament. 
The psoas muscle runs from the lumbar vertebrae to the 
lesser trochanter of the femur. Poupart's ligament runs 
from the anterior superior spinous process of the ilium to 
the symphysis. 

Adenoma. May become malignant, as sarcoma; many 
are benign, but some are most malignant — an epithelial 
tumor. 

Amenorrhea. Abnormal absence of menstruation. 

Aneurysm. A circumscribed dilation of the walls of 
an artery. 

Angioma. A tumor formed of blood-vessels — benign. 

Anomaly. An abnormal thing or occurrence, a marked 
departure from the normal. 

Anteflexion. A bending forward or doubling on itself 
forward. 

Antrum. A cavity or hollow space in a bone, as in 



TERMS USED IN SURGICAL DIAGNOSIS 107 

the mastoid, often infected; antrum of Highmore in the 
superior maxillary. 

Appendicostomy. Opening the vermiform appendix at 
the tip and irrigating the colon downward for the purpose 
of eliminating the germs which make that their abode. 

Appendix (vermiform). Small blind gut hanging from 
the cecum. 

Ascites. Obstruction of portal circulation in chronic 
heart and kidney diseases causing a collection of fluid in 
the peritoneal cavity. To let off this transudate we "tap" 
or do a "paracentesis" with a trocar, which passes through 
without infecting the peritoneum, with aseptic precau- 
tions. 

Asphyxia. Suffocation; lungs deprived of oxygen. 

Atheroma. A sebaceous cyst containing cheesy mate- 
rial. 

Atresia. Lack of normal opening; e. g., to the vagina. 

Atrophy. Diminution in the size of a tissue, organ, or 
part. 

Atypic. Not resembling its type; irregular, freakish. 

B 

Bartholin's glands. Vulvovaginal glands whose tiny 
openings appear about at the center of the inner surface 
of the labia minora, a seat of venereal infection. 

Benign, Benignant. Not endangering health or life. 

Bile-duct. The haunt of the Bacillus coli communis, 
the typhoid germ, etc. 

Boil. A furuncle; a localized inflammation of the skin 
and subcutaneous tissues with formation of pus. 

Bone-grafting. A new field in surgery, dating from 
about 1911, where a healthy bone is planted to splint and 
support or take the place of an unhealthy one, the callus 
thrown out by the irritated bone forming union; e. g., 
the tibia to the spine. 

Bubo. Suppurative inflammation of a lymph-node, 
usually in the groin and usually venereal. 



168 OPERATING ROOM 



Cachexia. Depraved condition of general nutrition 
due to syphilis, tuberculosis, or carcinoma; weak, tough, 
yellow, muddy skin, and emaciation. 

Calculus. Stones in the ureter, kidney, gall-duct, or 
bladder, sometimes causing occlusion of the ureters and 
consisting of uric acid, oxalate of lime, phosphates or 
cystin — a stone-like concretion inciting pyelonephritis — 
when in the gall-ducts, of bile pigment. See Gall-stones. 

Capsule. A receptacle or bag; covering of certain 
organs; e. g., the "kidney, the liver, some cysts, and parts 
of the eye. 

Carbuncle. Hard, circumscribed, deep-seated, painful, 
suppurative inflammation of subcutaneous tissue, larger 
than a boil, with a flat top and several points of suppura- 
tion. 

Carcinoma. Malignant epithelial tumor prone to local 
extension through the lymph-spaces. It may appear at 
any age and may have inflammation, ulceration, and 
hemorrhage. It is more frequently found in some parts 
of the world than in others. The age limit is said to be 
lower now only because patients are handing themselves up 
sooner to physicians and the complex life of this time 
ages people faster. Epithelioma occurs in skin where 
it joins the mucous membrane on the lips, eyelids, labia, 
mouth, esophagus, vagina, or cervix. It may not recur 
if thoroughly removed, and is the least malignant of the 
carcinomata. Cylindric-celled carcinoma occurs in the 
stomach, intestine, and uterus. Carcinoma simplex 
occurs in the mammae, stomach, liver, thyroid, salivary 
and prostate glands, in the pancreas, testicle, ovary, 
and kidney. Some of these are the most malignant. 
There has been no serum or toxin yet discovered as a 
cure, but early recognition and early - radical operation 
save many lives. 

Caries. Death of bone; similar to ulceration of soft 
tissues. 



TERMS USED IN SURGICAL DIAGNOSIS 169 

Caruncle. Small, fleshy growth, frequent in women, 
in the meatus urinarius. 

Chalazion. A tumor of the eyelid from retained secre- 
tion of the meibomian glands. 

Cholecystitis. Inflammation of the gall-bladder. 

Cholelithiasis. Presence of stones in the gall-bladder 
or gall-duct composed of bile pigment, that is, choles- 
terin and certain salts. By lying together they become 
facetted, and may exist in as large numbers as 7800. 

Cholesteatoma. Cells packed with cheesy matter, 
benign tumors in the dura behind the ear; found in 
mastoid operations. 

Chondroma. Benign tumor of the covering of carti- 
lage, but it may extend into the lungs or heart. 

Cicatrix. A scar; connective tissue replacing a local 
loss of substance, the new being red or purple, the old 
white, hard, shrivelled, and shiny. 

Circumcision. Removal of foreskin or prepuce for 
cleanliness and prevention of self -abuse. 

Cirrhosis. Chronic inflammation of an organ and over- 
growth of connective tissue. 

Clitoris. A very small organ in the female in front of 
the pubic joint, somewhat resembling the penis in the 
male, and extirpated to check self-abuse. 

Colic. Biliary. .Passage of gall-stones through the 
gall-duct into the duodenum. 

Renal. Pain caused by stone in the ureter. 

Appendiceal. Pain and rigidity of spasms due to in- 
flammation. 

Intestinal. Severe griping pain in the bowels due to 
spasm of the intestinal walls. 

Comedo (sing.), Comedones (pi.). Disorder of the se- 
baceous glands; in the young, yellowish elevations with 
black points in the center associated with acne. 

Condyloma. A wart-like growth or tumor near the 
anus. 

Congenital. Existing at and since birth. 

Convergent. Coming together, as in squint. 



170 OPERATING ROOM 

Cornu (sing.), Cornua — horns (pi.)- The projecting 
upper corners of the uterus into which open the Fal- 
lopian tubes. 

Cul de sac of Douglas. A pouch between the front 
wall of the rectum and the back wall of the uterus made 
by the peritoneum. 

Curettage. Curetment — scraping out the uterus. It 
is essential for the honor of the hospital to have a true 
history. 

Cyst. A cavity containing fluid and surrounded by a 
capsule. 

Cystocele. Hernia of the bladder. The back wall of 
the bladder drops down, pushing out the front wall of the 
vagina, the weight of urine increases this, and finally may 
pull down the cervix and the uterus. 



Decapsulation. Taking off the capsule of a diseased 
organ to establish new circulation and reduce inflamma- 
tion, as of the kidney, for nephritis or bichlorid poisoning. 

Dermoid cyst. A sac containing hair, teeth, nails, 
and other forms of epithelial tissue. 

Detritus. Waste matter from disorganization. 

Dilation. As correct as dilatation — act of stretching. 

Distal. Farther away from the point mentioned. 

Divergent. Going apart, as in squint. 

Diverticulum (of bladder or esophagus). A pouch or 
sac springing from a weakness in the wall of a main 
structure, causing the contents to stop there which should 
pass on; symptom of diverticulum of esophagus in an adult, 
regurgitation of food just as sweet as when swallowed. 

Dorsum. The back of the hand, foot, tongue, etc. 

Dura mater. Membrane covering the concave surface 
of the skull, "exposed" in ear operations under strict 
aseptic precautions, "going in" from outside, or the outer- 
most of the three coverings of the brain. 

Dysmenorrhea. Painful menstruation. 



TERMS USED IN SURGICAL DIAGNOSIS 171 



Ecchymosis. — Large diffuse accumulation of blood in 
the interstices of the tissues. 

Ectropion. A disease of the eyelid turning it inside 
out. 

Effusion. A pouring out of blood or serum into serous 
cavities (pleura, peritoneum, pericardium). 

Embolism. Blocking of a blood-vessel, especially an 
artery, by foreign matter. 

Embryonic. Pertaining to the embryo, or fertilized 
ovum of an animal. 

Encapsulated. Surrounded by a capsule, as a bullet 
or any other foreign body. 

Endometritis. Inflammation of the lining of the uterus, 
with swelling, congestion, and even hemorrhages. 

Endothelioma. A sarcoma in the lymphatics. 

Endothelium. Lining of blood- and lymph-vessels 
and of serous and synovial cavities. 

Entropion. A disease of the eyelid turning it outside 
in, so that the lashes constantly scratch the eyeball. 

Epididymitis. (Note spelling.) Inflammation of epi- 
didymis, small organ lying above the testes. 

Epispadias. Opening of urethra, not at the end, but 
on the upper side of the penis, due to arrested develop- 
ment. 

Epithelioma. Carcinoma of the skin and mucous mem- 
branes. 

Exostosis. Bony tumor; an abnormal projection of 
bone. 

Extra-uterine pregnancy. Gestation outside the uterus, 
in the tube, fimbriae, peritoneum, or on the intestines. 

Extravasation. Passing of fluid outside of a cavity 
in which it normally ought to stay (of blood or lymph). 

Exudate. The material that has passed through the 
walls of vessels into the adjacent tissues (said of serum or 
pus). 



172 OPERATING ROOM 



Felon. Inflammation of flexor tendons and tendinous 
sheaths of the finger. See Paronychia, Whitloiv. 

Fenestrated. Having a window or opening, as in a 
rubber drainage-tube, a pair of obstetric forceps, or a 
plaster cast over a sinus. 

Fibrin. Coagulating material in blood; small bunches 
of twigs are used to whip clots to separate the fibrin in 
looking for fetal or placental tissue. 

Fibroma. A tumor, benign at first, in skin and sub- 
cutaneous tissue may become serious through pressure, 
ulceration, etc. 

Fissure. A groove or cleft (normal) in the skull, 
brain, liver, cord, etc.; an abnormal fissure occurs at the 
junction of skin and mucous membrane, as the lips or the 
anus. 

Fistula (sing.), Fistulae (pi.), Fistulous (adj.). A narrow, 
winding, irregular canal in the soft tissues left by in- 
complete healing of an abscess or wound with fluid con- 
tents; must be entirely laid open and the edges bevelled 
off so as not to approach again (usually rectal). 

Flap. A piece of soft tissue cut on three sides of a 
square and laid back to cover a scar, or to bring forward 
after an amputation to cover a bone end. 

Floating. Free to move around; abnormal, as a kid- 
ney, which has no ligaments at all to hold it up, merely 
fat. 

Fossa. A depression or pit. 

Frenum. A rib or fold of skin or mucous membrane 
that limits the movement of any organ. Under a new- 
born infant's tongue an abnormal frenum should be 
promptly snipped or it cannot nurse and will be tongue- 
tied. 

Frontal sinus. Hollow air-spaces in the frontal bone; 
a seat of infection that becomes fatal at times through 
the easy way of reaching the brain; operated through the 
nose. 



TERMS USED IN SURGICAL DIAGNOSIS 173 

Furuncle. A boil. 

Furunculosis. The constant formation of a succession 
of boils. 

G 

Gangrene. Death of a considerable mass of tissue. 
When it is mummified, dry and hard, brown or black 
it is classified as dry gangrene; when discolored and 
putrefying, moist gangrene. It proceeds from wounds, 
diabetes, and other causes. It is not a cause for panic 
now, as formerly, in hospital wards. 

Glaucoma. Disease of the eye, with heightened" ten- 
sion, hardness of globe, lessening of visual power, restric- 
tion in field of vision, dreadful headache, etc.; relieved by 
iridectomy. 

Glioma. Tumor of neuroglia cells in the brain, cord, 
retina, nerves, and suprarenals; benign. 

Granulations. Formation of new vascular but nerve- 
less tissue in repair of wounds. 

Gumma. Third stage of syphilis in the brain. Should 
take precautions against contagion. It is a tumor with a 
gummy appearance, consisting of granulations and show- 
ing peculiar degeneration. 

H 

Hematocele. Blood extravasated into a closed cavity. 

Hematoma. Collection of blood in a tumor-like mass 
on a newborn infant's "caput," be it the head or but- 
tocks. 

Hemophilia. All words with the prefix hem (for blood) 
as their root should be spelled hem uniformly. Hemor- 
rhagic diathesis, condition of being a bleeder. Important 
question to ask in taking a history. When circumcising a 
newborn infant he proved a bleeder, and after all other 
means failed, a large number of the tiniest clamps ever 
made, covering the whole wound, saved his life. 

Hermaphrodite. A human being whose organs are so 
malformed as to partake of the nature of both sexes. 



174 OPERATING KOOM 

Hydatid mole (hydatidiform). Hypertrophy of the 
villi of the chorion, beginning as a fibrous mole; then its 
mucous membrane degenerates, then a hydatid mole. 

Hydrocele. Accumulation of fluid (serous) in the 
tunica vaginalis about the testicle or the spermatic cord. 

Hydrocephalus (the noun, note ending us). A head 
containing a collection of fluid in the cerebral ventricles, 
with steady increase in size. 

Hydrosalpinx. Fallopian tube dilated with water into 
the shape of a cyst. 

Hymen. A fold of mucous membrane partially closing 
the virginal vaginal opening. 

Hypospadias. The male urethral opening into a cleft 
on the under side (arrested development). 

Hypostasis. The settling of blood in the dependent 
or low-lying parts of the body. 



Ileus (volvulus). A twisting of the bowel so as to* ob- 
struct the passage of air, feces, or fluid; usually fatal. 

Impaction. A mass of fecal matter or calculi solidly 
packed; stones in the cystic duct cause dilation of the 
gall-bladder; very large stones sometimes cause occlu- 
sion of the gut. 

Imperforate. Without a normal opening, as of the 
anus (a hole from the rectum often leads to the vagina 
instead). 

Incarcerated. Walled in and bound around, as a 
hernia in a sac. 

Infarction. A circumscribed portion of tissue com- 
pletely infiltrated with blood. 

Infiltration. The entrance into the tissues (1) of some 
abnormal substance or (2) of some normal substance 
(as blood) in too great a quantity. 

Inflammation. Heat, swelling, redness, pain, and im- 
pairment of function; a rush of leukocytes to fight the 
invasion of bacteria. 



TERMS USED IN SURGICAL DIAGNOSIS 175 

In situ. Iii the natural position. 

In statu quo. In the natural condition. 

Intercostal spaces. The muscular areas between the 
ribs, numbered. 

Intussusception. Slipping of one part of the intestine 
into the part beyond; telescoping of the bowel on itself, 
as the ileum into the colon. 

Invagination. Act of insheathing or being run into a 
sheath, as inverting the raw end of the appendix stump 
inside itself. 

K 

Keloid. An overgrowth of tissue standing out like a 
very full frill, usually in any old scar, and very common 
in the negro race. 

Kidneys. Subject to inflammation, have no support- 
ing ligaments, malformations quite common, as two in one 
or one missing, or one with two ureters, have tumors of 
various kinds; the healthy one should not be removed by 
mistake, this being the result of carelessness in marking 
specimens obtained after catheterizing the ureters. 



Laceration. A tear, especially of the cervix or peri- 
neum in childbirth; repair is imperative. 

Lamina. Plates or layers applied to vertebrae. 

Laminectomy. Removal of the posterior arches of the 
vertebrae. 

Lateral. Belonging to the side; in a sideways direc- 
tion. 

Leiomyoma. Benign tumor of involuntary muscle. 

Lesion. An injury, a wound, or any diseased morbid 
condition in an organ. 

Leukocytes. White corpuscles. 

Leukorrhea. Whitish mucopurulent discharge from 
the female genital canal. 

Lipoma. Benign, fatty tumor. 



176 OPERATING ROOM 

Lobe. A rounded part of an organ, separated from 
the others by fissures or clefts. 

Longitudinal. Lengthwise; in the longest direction of 
the body. 

Lymphangioma. Benign but may rupture; a tumor 
made of lymphatic vessels. 

M 

Malformation. An abnormal development or forma- 
tion of a part of the body. 

Malignant. Applied to tumors; harmful, fatal. Known 
if (1) they spread by metastases; (2) they invade adja- 
cent material by eccentric or peripheral growth; (3) they 
tend to recur; (4) they interfere with the nutrition and 
general well-being of the body, inducing cachexia. 

Malposition. An abnormal position of any part or 
organ. 

Mastitis. In infants streptococcic or staphylococcic 
infection. Use no pressure, no massage. Inflammation of 
the breasts found in nursing mothers. 

Mastoiditis. Inflammation of mastoid cells behind the 
ear. 

Do not confuse these two terms. 

Median line. A line in the center of the body from the 
umbilicus to the symphysis pubis; imaginary. 

Menorrhagia. Excessive menstrual flow. 

Metastasis (sing.), Metastases (pi.). Transfer of dis- 
eased particles by the blood or lymph from the primary 
bed to a distant one. 

Metrorrhagia. Uterine hemorrhage; not connected 
with the menses or childbirth. 

Microcephalon. An abnormally small head. 

Milium. Small, pearly, non-inflammatory elevations 
on the skin due to plugging of sebaceous glands. 

Mole. Birthmark; a pigmented nevus. 

Mouse-tooth. Forceps with sharp teeth like a mouse's; 
Do not be guilty of saying "mouth-tooth." 



TERMS USED IN SURGICAL DIAGNOSIS 177 

Multilocular. Having many cysts or "eyes" — middle 

(1) put in for ease in pronouncing. 

Multiple. Affecting many parts at the same time. 

Myoma. Benign muscular tumor, frequent in the 
uterus. 

Myxoma. A benign growth in connective tissue, but 
may recur; containing mucin, like Wharton's jelly in the 
umbilical cord. 

N 

Naevus or Nevus. Vascular birthmark; "strawberry 
mark"; an angioma full of blood-vessels, benign and con- 
genital, corrected by skin-grafting. 

Necrosis. Death of a limited portion of tissue due to 
insufficient nutrition by (1) cutting off the blood-supply; 

(2) bacteria; (3) mechanical injury. 

Neuroglia. Has its origin in nervous tissue, but takes 
on the duties of connective tissue. 

Neuroma. Benign tumor; new formed nerve tissue. 

Node. A knob, swelling, or protuberance; the normal 
shape of many lymph-vessels. 

Nodule. A little node. 

Noma. Not surgical. An ulcer in the cheek rapidly 
spreading down the alimentary canal. 

O 

Obliteration. Removal or disappearance of a part. 

Obstruction. Blocking of the blood or the bowel. 

Occlusion. Closing or blocking off, as of the Fallopian 
tubes, inducing sterility; or of the gall-duct with gall- 
stones. 

(Edema or Edjema. Infiltration of serum into a part. 

Omentum. Useful for absorption and its fat supply; 
a fold of peritoneum hanging down like an apron in front 
of the intestines. 

Oophoritis. Note spelling, marking, and pronuncia- 
tion, not like oo in foot, but like oa in oasis. An inflam- 

12 



178 OPERATING ROOM 

mation of the ovary after the puerperium, or it may be a 
primary affection. 

Orchitis. Inflammation of the testicle. 

Organized clot. Found in curettings; blood converted 
into something looking like an organ or other living 
tissue. When curettings are examined they should be 
whipped with a bunch of twigs to separate the fibrin so 
as not to miss a tiny fetus. 

Osteitis or Ostitis. Inflammation of bone. 

Osteoclast. An instrument for breaking bones (bow- 
legs). 

Osteoma. When alone, benign; new formed bones 
found in the soft parts, such as the pleura or the dia- 
phragm, but often combined with sarcoma. 

Osteomalacia. A disease mostly of pregnant women; 
by the loss of inorganic salts bone which was hard and 
fully formed becomes softened and twisted, sometimes 
necessitating cesarean section. 

Osteomyelitis. Inflammation of the marrow of bone. 

Osteoplasty. Operation for bow-legs or knock-knees, 
for the cosmetic effect. 

Osteosarcoma. A sarcoma containing bone. 

Otitis media. Inflammation of the middle ear. Diag- 
nostic : 

0. m. c. c. Otitis media chronica catarrhalis. 

0. m. c. a. Otitis media catarrhalis acuta. 

0. m. p. c. Otitis media purulens chronica. 

0. m. p. a. Otitis media purulens acuta. 

Ovary transplantation. Taking a healthy ovary from 
one woman and sewing it into place in the body of an- 
other woman (1) to correct sterility; (2) to keep the val- 
uable ovarian secretions acting to prevent neurasthenia 
or masculinity. 



Papillomata. Warty growths, fibromata, of the skin; a 
papillary outgrowth covered with epithelium. 
Paracentesis, Puncture into a body cavity (ear, ab- 



TERMS USED IN SURGICAL DIAGNOSIS 170 

domen, bladder, thorax, cornea); a "paracentesis knife" 
for ear work has a very small two-edged blade, so small 
that it can pass through a small ear speculum. 

Parenchyma. The essential or working part of an or- 
gan [e. g.j the kidney); the body without the covering. 

Paresis. Some, but not complete, loss of muscular 
power (intestinal). 

Patent. Open or exposed, as a valve. 

Patulous. Expanded or open. 

Pedicle. The stem or stalk of a tumor or cyst. 

Pediculated cyst. Growing from the broad ligament 
and having a pedicle. 

Perichondrium. The fibrous coat of cartilage. 

Perineum. The floor of the pelvis from pubes to 
coccyx (adj., perineal). 

Peritoneum. Serous sac lining the whole abdominal 
cavity and containing the viscera (adj., peritoneal). 

Peroneal. Pertaining to the fibula, or small bone of 
the leg. 

Do not confuse these three terms. 

Periosteum. Fibrous covering of bone — not to be 
destroyed. 

Periostitis or Periosteitis. Inflammation of the perios- 
teum. 

Petechiae. Very minute hemorrhages into the skin; 
sometimes seen in the newborn and others (adj., petechial). 

Phagedena. A rapidly spreading destructive ulcer of 
the soft parts. 

Phlegmon. Inflammation with spreading of purulent 
exudate within the tissues. 

Pia mater. Membrane covering the convex surface of 
the brain, the middle one of the three meninges. 

Pneumothorax. Air in the pleural cavity — (1) injury 
to the chest wall, going into it from without, (2) or from 
the lung channel, as if coming out, (3) or by ulceration or 
suppuration in adjacent organs, intestines, esophagus, etc. 

Polypus. A tumor with a pedicle, as a growth in the 
ear, nose, bladder, uterus, urethra, or rectum. 



180 OPERATING BOOM 

Prepuce. Foreskin; fold of skin lined with mucous 
membrane under which dirt accumulates. 

Primary union. The clean joining of two edges of a 
wound, as in a herniotomy. One should always be very 
ambitious to have primary union of severed tendons; for 
instance, w T here function would be seriously impaired. 
Divided nerve ends cannot have union. 

Procidentia. Prolapse, a falling down (of the uterus). 

Prolapse. A falling down (as of the rectum). 

Prostatitis. Inflammation of the prostate gland from 
old age, injuries, or gonorrhea. 

Proximal. Of the two ends of an object; the nearer to 
a chosen point. 

Psoas. Muscle of the loin and pelvis. 

Ptosis. Drooping of the eyelid with loss of nerve 
power; dropping of the intestine or stomach. 

Purulent. Not pussy. Containing pus. 

Pus. Liquid formed of dead and living bacteria and 
leukocytes; also the fluids they have thrown off in their 
conflict in a part that has been inflamed. 

Pustule. A small elevation on the skin containing 
pus. 

Pyaemia or Pyemia. Following septicemia fresh sup- 
purating foci are developed all over the body; metastatic 
abscesses. 

Pyelitis. Inflammation of the pelvis of the kidney 
(the main part). 

Pyosalpinx. A tube distended with pus. 

R 

Rachitis. Malformation of chest and bones due to im- 
proper nourishment. When placing a rachitic patient on 
the operating-table one is surprised to find such irregular- 
ities in the bones of the legs that they can hardly fit into 
the stirrups. 

Ranula. A small tumor, very troublesome, in Whar- 
ton's duct obstructing the salivary fluid. 



TERMS USED IN SURGICAL DIAGNOSIS 181 

Rectocele. A sac of relaxed vaginal wall, posterior, 
pushed down by the relaxed front wall of the rectum. 

Rectovaginal fistula. Usually congenital; unclean; 
accompanying imperforate anus. 

Renal. Pertaining to the kidneys. 

Resolution. Return of a part to normal after some dis- 
eased condition, as of the lung in pneumonia. 

Retained (placenta). Left in when it should normally 
come out, also as of a soapsuds enema. 

Retroflexion. Bent backward on itself (uterus). 

Retroversion. Falling back as a whole without doub- 
ling on itself. 

Rupture. A bursting of a sac or blood-vessel (also of 
an inflamed appendix) ; the lay word for hernia; incorrect 
because there is only displacement. 



Sac. A bag or the bulging cover of a cyst or tumor; 
in hernia, the bag growing around the dropped loop of 
intestine; a natural cavity. 

Sarcoma. Travels by way of the blood-vessels, to dis- 
tinguish it commonly from carcinoma. It is malignant 
and found in early life. It occurs in the skin, subcuta- 
neous tissue, subserous connective tissue, fasciae, perios- 
teum, and choroid of the eye most frequently. It is also 
found in the brain, cord, lymph-nodes, uterus, ovary, 
bladder, and kidney, from which last it can be projected 
into the lungs and heart. 

Sebaceous. Pertaining to the oil-glands of the skin. 

Septicaemia or Septicemia. A condition in which bac- 
teria and their toxins are distributed all through the body 
by the blood and the lymph. 

Septum. A partition, may be deviated, in the nose; 
sometimes a double vagina is found with a septum be- 
tween the two halves. 

Seropurulent. Having partly the nature of both serum 
and pus. 



182 OPERATING ROOM 

Serous. Pertaining to or resembling serum. 

Serum. Clear yellowish fluid separated from the blood 
after the coagulated fibrin is removed. 

Severed. Cut in two, as a tendon or a nerve. 

Sinus. (1) A large channel containing blood, as the 
lateral sinus, disturbed in some ear operations; (2) a 
cavity within a bone (frontal); (3) a worm-like opening 
from tissues for drainage in an old wound; an effort of 
nature to show that some foreign body has been left in, 
as silkworm-gut instead of chromic gut. 

Slough. Death and throwing off of tissue, as after a 
deep burn. 

Spasm. Sudden muscular contraction with pain. 

Stenosis. Constriction or narrowing of a passage so 
that what should normally pass through cannot, as aortic 
stenosis or stenosis of the cervix. 

Strangulated. Compressed and twisted so as to cut off 
the blood-supply, as in a hernia; black and gangrenous. 

Strabismus. Squint. Do not say "strabismuth"! 

Stricture. Narrowing of a canal from inflammation of 
its inner walls; frequently from infection, not always. 

Subinvolution. Imperfect contraction of the uterus 
after childbirth. 

Supernumerary. Extra, as of a thumb or any other 
digit sprouting out from the base of the normal one. 

Synovitis. Inflammation of the synovial membrane; 
may be suppurative. 



Teratomata. Congenital growths containing all forms 
of connective tissue (cartilage, hair, skin, teeth, nails, 
bone, glands), and found in the end of the spine, head, 
neck, glands, and generative organs, probably part of 
another fetus. 

Thickening. A swelling due to old inflammation. 

Thrombosis. Organized blood-clot blocking a vein. 

Tight lacing. Cause of displacement of kidneys, pan- 
creas, liver, and uterus. 



TERMS USED IN SURGICAL DIAGNOSIS 183 

Torsion. Twisting, as a big tumor on its pedicle, be- 
coming a strangulation. 

Transplantation. Applying to one part the tissues 
taken (1) from the same body; (2) or from the same part 
of another body like it. 

Transposition. Wrong position from birth, as liver on 
the left, heart on the right, etc. 

Transudation. Passing of fluid through a membrane, 
as blood through its vessel walls. 

Trauma. Condition of being wounded. 

Tubal pregnancy. Growth of fertilized ovum in the 
tube. 

Tubercle. A specific lesion produced by the germ of 
tuberculosis (the tubercle bacillus); a nipple or nodule of 
diseased tissue visible to the naked eye. 

Tuberculosis of the joints or peritoneum is operable; 
opening for drainage or exposure to direct sunlight. 

Tumors. Circumscribed new growths of tissue — 
nodular, tuberous, fungoid, polypoid, papillary, dendritic, 
or lobulated. Some are benign, others malignant. 

U 

Ulcer. Gradual death of the tissue of the skin or 
mucous membranes. 

Ulceration. Necrosis with erosion (wearing off) in- 
volving the surface of the skin, mucous or serous mem- 
brane, due to inflammation or cutting off of nutrition. 

Urachus. Remains of fetal life sometimes found in the 
abdomen during an operation for a different purpose; a 
canal about 6 cm. long, with a small opening into the 
bladder or entirely closed at that place; if there are certain 
congenital malformations the urine may flow through 
the urachus; in the adult a slight distention visible up to 
the navel shows that the urachus was never obliterated. 



184 OPERATING ROOM 



Varicocele. Veins of the spermatic cord dilated and 
forming twisted masses. 

Varicosity. A swollen vein, knotted and tortuous, 
resembling a bunch of grapes. 

Vascular. Having many blood-vessels. 

Vesicovaginal fistula. Requires a special bed; an open- 
ing from the bladder to the vagina with constant dribbling 
of urine; very common after childbirth, due to pressure 
and necrosis before the invention of obstetric forceps. If 
a patient's bladder is full the surgeon may snip it acci- 
dentally, causing a vesicovaginal fistula. Sims earned 
the eternal gratitude of his time by repairing it com- 
pletely with silver wire. 

Vicarious. Relating to an habitual discharge of blood 
in an abnormal part of the body, but never in the vagina, 
as a substitute for menstruation. 

W 

Walled-off. Shut in or bounded by a solid body of 
leukocytes in nature's effort to check the invasion of 
bacteria. 

Wen. A sebaceous cyst. 

Whitlow. Same as Felon. 



CHAPTER XIV 



LIST OF INSTRUMENTS FOR CERTAIN 
OPERATIONS 



Head. — General Work. 

Scalpels. 

Mouse-tooth forceps. 

Anatomic forceps. 

Artery clamps. 

Scissors. 

Sharp retractors. 

Periosteal elevators. 

Trephines. 

Gigli saw with its handles 

(Figs. 21, 22). 
Bullet searcher. 
Rongeurs. 




Fig. 21.— Gigli saw. 



Sharp curets. 

Mallet. 

Chisels. 

Gouges. 

Probes. 

Aspirating needles and 

syringe. 
Needle-holder (Fig. 23). 
Bone-wax. 

Twisted catgut drain. 
Rubber tissue drain. 




Fig. 22.— Handles for Gigli 
saw (in pairs). 



Needles. — (1) Small round body and very fine catgut 
for the meninges; (2) medium-sized curved Hagedorn for 



185 



186 OPERATING ROOM 

scalp for silkworm-gut or silk (to be removed), or curved 
needle with cutting edge. 

Accessories. — Lighting of the room, headlight, dress- 
ings, towels, laparotomy sheet, sand-bags; sterilize elec- 
trodes, cover all electric appliances near the wound with 
sterile gauze; have clippers, a safety razor, and a good 
common razor; put a bandage around the brow for con- 
striction; starch bandage is put over all and wet to set; 
the hair at the edge of the shaved area is plastered down 
with gauze steeped in collodion. 

Notes. — The head nurse should make a drawing of the 
various layers — hair, scalp, periosteum, bone, dura 
mater, pia mater, arachnoid membrane, and brain tissue. 



Fig. 23. — Richter needle-holder (5§ to 8 inches). 

For all intracranial work keep the blood-pressure apparatus 
on hand. 

Mastoid. — This list provides enough for the assistant 
also: 

5 rongeurs (McKernon, Adams, Pyle, Janvier, bulldog). 

1 mallet. 

3 chisels (graded). 

3 gouges (graded). 

4 spoon curets. 

2 ring curets. 

2 periosteal elevators. 
2 sharp retractors. 

1 mastoid self -retaining retractor. 

2 Mayo retractors. 

2 mouse-tooth forceps. 
2 thumb forceps. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 187 

2 grooved directors. 

2 probes. 

2 scalpels. 

2 scissors (straight blunt, curved blunt). 

1 needle-holder. 

12 artery clamps (6 curved, 6 straight). 

1 mastoid syringe (metal ground, no washers). 

6 needles (2 small curved round body for possible use 
of catgut Nos. 1 and 2; 4 medium-sized full-curved Hage- 
dorn for silkworm-gut for the skin) and silk suture mate- 
rial. 

Accessories. — Nurses' sponge table must always have 
scissors, thumb forceps, and in abdominal cases long 
uterine dressing forceps are very handy; plain gauze 
packing; iodoform packing; a nurse usually holds retrac- 
tors; use stout needles for the scalp, but in a radical opera- 
tion use small round needles for the narrow, deep cavity; 
one glass basin for 95 per cent, alcohol; medicine glass, 
smear-glasses; slides; swabs; special mastoid dressing, 
mastoid tips; three bundles special sponges; towels; 
pitcher; saline; carbolic acid (5 per cent.) and basin to steep 
an old syringe with leather washers; one plug of iodoform 
gauze for the sinus; one narrow strip of plain gauze for 
the canal. 

Notes. — Special dark room or darkened room; watch 
ventilation. In applying bandage move patient up 
until his shoulders are over the head of the table, then 
support by the hair and the shoulders; watch for pus, 
and do not sponge it away, wait for a smear to be taken; 
infections may run the full length of the sternocleido- 
mastoid. The ward nurse should be severely punished 
if the patient's head has pediculi or if the hair is not prop- 
erly combed and braided in the special mastoid way, 
slanting toward the good ear. The hair must be fastened 
down along the edge of the shaved area by a strip of gauze 
steeped in collodion, sand-bag under neck — a special 
shaped sand-bag, small and flat. 



188 OPERATING ROOM 

Cataract Operation. — Instruments generally brought 
or selected by the operator: 

Right or left speculum. Iridectome. 

Fixation forceps. Cystotome. 

Cataract knife. Spoon. 

Iris forceps. Iris repositor. 

Iris scissors. 

Accessories. — A bandage (2-inch), very best gauze, 
double figure-of-8; special woven woolen or linen bandages, 
p. r. n., black satin mask over all; eye pads; gauze to drop 
lens on; cotton moistened in sterile water for sponging 
leaves no threads; no pressure on eyeball; assistant must 
be in good physical shape to hold the lens steady; be sure 
which eye is to be operated on; cover the good eye; keep 
blood washed off instruments during the operation. 
All orders must be most accurately written down con- 
cerning wraps, catharsis, diet, etc. The ethical behavior 
of the hospital staff preceding a cataract operation has 
much to do with the patient's behavior during the cutting. 
If they instil confidence, his nervousness being reduced, 
he will not "squeeze" so much. 

Notes. — For nursing cataract cases the patient must 
keep his orientation by being told where he is taken after 
bandaging. When putting him to bed the nurse tells him 
which direction his head is toward, etc. He must not 
catch cold and sneeze; there should be no draughts on or 
near him; he must be lifted more gently than any other 
patients. Cleanse eye knives in benzine or in soapy 
water and alcohol, rinse and wipe on old soft linen. Test 
knives on a drum for sharpness — i. e., a kid glove wrist 
stretched over a napkin ring or a tiny embroidery hoop. 
Boil blunt instruments only. 

Submucous Resection of the Nasal Septum. 

Nasal speculum. 

Applicators, metal, for the preliminary cocainization to 
swab strong cocain on the mucous membrane; wooden, 
previously wound with cotton on both ends, for wiping 
blood from the field during the operation. Of these 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 189 

there should be several dozen sterilized and ready for 
use. 

Septum knife. 

Elevators, of which the Freer and the Killian are the 
most common types (sharp and dull). 

Ballenger. swivel knife (two sizes). 

Speculum or retractors for separating the flaps. 

Forceps (various types) for removing portions of the 
bony and cartilaginous parts of the deflected septum. 

Chisels (flat or grooved, or both). 

Mallet. 

Septum or intranasal needles for the insertion of 
sutures. 

Sutures — silk. 

Nasal dressing forceps. 

Gauze strips, iodoform or plain (packing), or the Beck 
rubber nasal packing bags made on the principle of the 
Voorhees obstetric bags, inserted, filled, and pressing to 
prevent hemorrhage. 

Syringe of 5-c.c. capacity if injection method of anes- 
thetization is employed. 

Frontal Sinus Operation (Radical). — A radical -opera- 
tion is made by a wound between the brows; an indirect 
or conservative is done intranasally. An acute infection 
at its first height may be successfully treated intranasally. 
but a chronic or neglected acute case must be treated 
radically. 

Small trephine; diameter of not over 5 mm. 

Scalpel. 

Thumb forceps (dissecting). 

Artery clamps (6). 

Periosteal elevator. 

Chisels, gouges, and mallet. 

Electric burr or drill is preferred by some operators. 

Curets. 

Intranasal bone forceps of various types. 

Wound retractors. 

Probe. 



190 OPERATING ROOM 

Scissors (straight and curved on the flat). 

Needle-holder and silk gut for the skin on Hagedorn 
curved needle. 

Radical Operation on the Ear (Removal of Ossicles). — 
Same as Mastoid plus: 

4 cotton applicators. 

2 flap knives. 

1 gauze strip for retractor (to pull ear forward, out of 
the way). 

Specula (graded sizes). 

10-day chromic gut No. 10. 

Accessories. — Some men do a skin-graft into the middle 
ear from the patient's thigh. Others cover the graft with 
some fine prepared sterilized animal membrane to facilitate 
its "taking." 

Jugular Operation Following Sinus Thrombosis. — 
Always an emergency operation, a septic thrombus in 
the lateral sinus, causing chills and fever, to relieve which 
a portion is excised and collateral circulation established. 

Infusion set for shock. 

Scrubbing-up set. 

Saline, cold and hot. 

Silk gut. 

Blunt retractors (so as not to puncture the vein). 

An extra stock of artery clamps. 

A plug of gauze for the sinus. 

Iodoform and boric acid powders in insufflators (sterile). 

Stout ligatures of plain catgut No. 3 for the two ends of 
the excised vein. 

Note. — Save the specimen; have hot- water bottles 
with double flannel covers in readiness; bandages, 2-inch 
gauze. 

Strabismus, Operation for. 

Speculum. 

Fixation forceps. 

Conjunctiva forceps and scissors. 

Strabismus hook. 

Tendon scissors and sutures. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 191 

Conjunctival sutures — 6 black silk sutures, 8 inches 
long, iron-dyed, on small curved needles — have ready 
early. 

Enucleation of Eye. 

Speculum. Stronger scissors. 

Fixation forceps. Pressure pad (to stop ooz- 

Conjunctiva scissors. ing). 

Strabismus hook. Conjunctival sutures (see 

Tendon scissors. above). 

Accessories. — Two flat pads of cotton, diameter 2\ 
inches, moistened in boric acid (2 per cent.), to lay in the 
empty socket, then dry absorbent cotton. 

Notes. — Mark carefully the eye to be enucleated so 
that there will be no mistake. Cover the good eye. 

Adenoids. 

Mouth-gag. Adenoids forceps. 

Tongue depressor (metal). Adenoids curet. 

Headlight. 6 sponge forceps. 

Tonsils. — Add long blunt scissors curved on the flat, 
tenaculum forceps, tonsil snare (or tonsillotome, old 
method). Tonsil dissecting knives, right and left, wires 
to thread snare, and the tonsillar hemorrhage needle de- 
signed by Dr. Lovell and made by Ermold. 

Accessories. — Alcohol (95 per cent.), adrenalin (1: 1000); 
rubber cap for patient. Neck of gown very loose. 
Rubber sheet for turning patient from left shoulder out 
over chest under right shoulder, and at least | yard out 
from left shoulder again; it should be one-half as long 
again as the patient's measure around the shoulders. 
Waste pail with sieve to drain sponges; sterile towel over 
rubber; laparotomy sheet; towels in a basin of ice with 
just enough water to wet them through; numerous small 
sponges on sponge forceps; severe hemorrhages may 
occur. 

Notes. — Protect walls, floor, and furnishings. Do not 
throw out specimens; the surgeon will want to show them 
to the parents. Keep the patient at the extreme right of 
the table; wipe his nose frequently to let air through, 



192 OPERATING ROOM 

with a downward stroke; let the air clot the vessels in the 
adenoid area. Patient goes down on the stretcher face 
downward, also in bed. 

Pharyngeal Abscess. — Knife, all the blade wound with 
adhesive except the first \ inch at the tip to prevent its 
going in too far. If the patient chokes, use artificial 
respiration and run for the tracheotomy set. Hemorrhage 
may ensue, in which case the methods after tonsillar hem- 
orrhage are used. Let the patient sit up, if not anes- 
thetized, in bed with a back-rest. Turn him quickly to 
the same side, so that pus may flow down the same cheek 
without crossing the epiglottis. 

Accessories. — Lights, rubber sheet around patient's 
neck, pus basin and waste pail, mouth-wash. 

Tracheotomy. 

Scalpel. 

2 mouse-tooth forceps. 

Artery clamps. 

Medium and small sharp retractors. 

Small blunt retractor. 

Curved and straight scissors. 

Probe. 

Dressing forceps. 

Needle-holder and needles. 

Tracheotomy tubes, assorted sizes, with their inner 
tubes. 

Accessories. — Tape in tubes; tie at one ear; split com- 
presses; gauze fluffs wet in soda bicarbonate solution; 
oiled silk bib; pheasants' feathers. When the inner 
tube comes out mark its length on a feather and never put 
the feather in any farther. Do not tickle the trachea; do 
not expose the patient's chest for fear of pneumonia. 

Brain Abscess (from Mastoiditis). 

2 brain knives, curved and straight. 

Spade retractors, very large, square 

Clamps. 

Encephaloscopes, 3 sizes. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 193 

Skin-grafting. 

Special skin-grafting razor with thin edge, thick back, 
and handle adjusted at a slant. 
Tissue curet. 
Scissors, blunt, curved on the flat. 

3 spatulae, assorted sizes. 

2 packers (to pick at skin on spatula). 

4 slides. 

Cotton applicators. 

Tepid saline in glass dish. 

1 pipet. 

Sponges. Towels. 

Roller dressing. 

Silver leaf (in book), sterile or rubber tissue. 

Flat compresses. 

Adhesive straps. 

Pledgets of aristol (fluffed cotton, size of peas, rolled in 
aristol) sterilized in glass test-tubes, and dropped to place. 

Notes. — For a burned area the scissors or curet may be 
used to remove excessive granulations. Assistant or 
nurse may keep saline dripping on razor and graft (sub- 
stitute for blood) . 

Breast Amputation. 

Dissecting set. 

Very large number of artery clamps. 

Drainage-tubes. 

Ligatures of plain catgut No. 1 (very many). 

Silk or silkworm-gut for skin sutures. 

Tension sutures (silkworm-gut) at surgeon's choice 
(long). 

Needle-holder. 

Needles, usually curved Hagedorn or cutting edge, but 
may be straight Hagedorn. 

Accessories. — Large gauze pads; hot saline towels on 
large bared area; cotton under axilla, hand, and at elbow; 
4- to 6-inch bandages of gauze and muslin; a special breast 
binder (Figs. 24, 25) with a sleeve for the affected side, 
the sleeve being split on the upper side and fastened with 

13 



194 OPERATING ROOM 

tapes. This holds all the axillary dressing beautifully 
secure. Be prepared for shock and hemorrhage. An 
additional nurse holds the arm above the patient's head. 
Do not allow the orderly to be present. A very large area 
must be prepared for this operation, per the rules of the 




Fig. 24. — Binder for breast amputations — sleeve spread to show 

pattern. 

house as written in the standing-order books. Every 
vessel is tied off. 

Empyema: (a) Aspiration, (b) Incision, and (c) Rib 
Resection. 

(a) Aspiration. — Unless otherwise specified, the pa- 
tient is prepared posteriorly on the side affected. Set 
a child up over the nurse's shoulder. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 195 

Syringe and needles in good order. 

Iodin. 

Cotton. 

Collodion. 

Gauze. 

Large graduate to measure pus, unsterile. 




Fig. 25. — Binder for breast amputations — sleeve folded. 

Rubber sheet to protect patient and bed. 

Towels. 

Basins, assorted, to hold pus. 

Camel's-hair brush. 

Sponge forceps. 

Small glass graduate, sterile, for specimen to laboratory. 



196 OPERATING ROOM 

(b) Incision. — Lay child on the good side, resting her 
anterior chest wall on the pillow (covered with rubber), 
bringing her arm forward so that she does not lie on it. 

Scalpel. 
Hemostats. 

Ligatures, No. 1 catgut plain. 
Curved scissors. 
Sharp retractors. 
Mouse-tooth forceps. 
Thumb forceps. 
Drainage-tubes. 
Pus basin. 

Graduates (sterile, small; unsterile, large). 
Note. — Note change in color, respirations, etc.; point 
out all such data to juniors for instruction. 

(c) Rib Resection. — Add to set in (b) : 
Periosteal elevator. 

Costotome (rib-cutting). 

Bone hook. 

Needle-holder. 

Round needles for ligatures (No. 1 catgut plain). 

Silkworm-gut on curved Hagedorn for skin. 

Rubber-dam and drainage-tube. 

Politzer bag and tube bottle from oxygen tank, the 
latter to produce vacuum and extract pus, or empyema 
button (spool). 

Pads, towels, sponges. 

LTnguentine or boraline to smear over skin before ap- 
plying rubber-dam. 

Appendectomy. 

Intestinal forceps to grasp colon (Fig. 26). 

Scalpel. 

Mouse-tooth forceps. 

Plain forceps. 

Artery forceps. 

Sponge-holders. 

Retractors. 

Ligature carrier. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 197 




Fig. 26. — Viscera forceps. Method of covering jaws with rubber 

tubes. 



Ligatures — catgut No. 1 for abdominal wall; catgut 
No. 2, chromic, to ligate appendix. 
Scissors, curved and straight. 



198 OPERATING ROOM 

Specimen dish. 

Cautery. 

Carbolic acid and alcohol (pure). 

Needle-holder. 

Probe. 

Split compress. 

Rolled gauze to wall off. 

Saline. 

Tape sponges with rings slipped through their tapes. 

Drainage-tubes. 

Cigarette drains. 

Towels. 

Towel clamps. 

Outfit for lavage. 

Needles — (1) Small round c catgut No. 1 plain for peri- 
toneum; (2) stout short round c chromic No. 2 for muscle; 
(3) straight cambric needle or fine round intestinal needle, 
with fine silk for purse-string suture to invaginate the 
stump; (4) long, heavy curved needles with silkworm-gut 
for through-and-through outer sutures, especially if 
around drainage-tube, or Michell clips, with special 
forceps (Figs. 27, 28). 

Cholecystotomy, Cholecystectomy, Choledochotomy. 

Dissecting set. 

Long stout probes. 

Gall-stone spoons (Fig. 29). 

Gall-stone forceps. 

Gall-bladder clamp. 

Long sounds. 

Artery clamps. 

Ligatures (catgut No. 3). 

Aspirating syringe and needles. 

Sponge forceps. 

Scissors (blunt, curved, straight). 

Retractors. 

Cautery. 

Carbolic acid and alcohol. 

Specimen dish. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 199 



i\ 



Fig. 27. 



Fig. 28. 



d 




Figs. 27, 28.— Fig. 29.— Fig. 30.— Gastroenterostomy 

Michell's suture Mayo's double- forceps — 3 blades, 13 J inches, 
clips and forceps, ended gall-stone 
scoop. 



200 OPERATING ROOM 

Sterile pus basin. 

Drainage-tubes. 

Packing (plain gauze, two widths). 

Gauze to wall off. 

Sponges. 

Tape-sponges on rings. 

Rubber tissue apron. 

Sutures and needles — (1) fine silk on small round body, 
full-curved, for deep work on gall-bladder; (2), as in 
appendectomy. 

Needle-holders, two sizes. 

Small hemostatic needle in opening duct, with silk. 

Gastrostomy, Gastro-enterostomy, Gastrectomy. 

Dissecting set. 

Retractors. 

Sponge forceps. 

Ligatures (chromic Nos. 2 and 3). 

Artery clamps. 

Ligature carrier. 

Scissors (curved and straight). 

Stomach clamp (Fig. 30). 

Needle-holder. 

Gauze packing, plain. 

Gauze rolls to wall off. 

Saline. 

Tape-sponges on rings. 

Sponges. 

Needles (fine silk or straight needles, plain and chromic 
catgut, as for other laparotomies). 

Drainage-tube. 

Fluffs of gauze. 

Cotton pads. 

Outfit for lavage, tube, pus basin, pail, pitcher of tepid 
water, rubber sheet. 

Hysterectomy. 

Dissecting set. 

Retractors, 3 sizes. 

Clamps (6 long straight, 6 long curved, 12 small). 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 201 

2 aneurysm needles, right and left (Fig. 31). 

1 bladder sound, to mark the top of the bladder. 





Fig. 31. — Aneurysm needles, right Fig. 32. — Vulsellum forceps 
and left. (double tenaculum). 



6 sponge forceps. 

Dressing forceps (uterine) to thrust into vagina to draw 
down drain. 



202 OPERATING ROOM 

Vulsella, extra strong (Fig. 32). 

Cautery. 

Aspirating syringe and needles. 

Ligatures (braided silk for pedicle; plain catgut No. 2 
for adhesions; plain catgut No. 4 for broad ligaments). 

Pedicle clamps. 

Blunt scissors, curved on the flat. 

Blunt straight scissors. 

Sharp scissors (straight, curved). 

Tape-sponges on rings. 

Hot saline. 

Vaginal packing. 

Extra glove for nurse guiding packing. 

Sponges. 

Needle-holder. 

Sutures (catgut No. 1 for flaps on small curved needle; 
catgut No. 2 for broad ligament on half-curved needle). 

Notes. — Be prepared for collapse when in Trendelen- 
burg. Provide many footstools, graded in height and 
length. 

Cesarean Section. 

Dissecting set. 

2 large clamps for the cord. 

2 aneurysm needles. 

Stout Esmarch rubber tourniquet. 

Sutures of heavy silk in half-curved needles, fine silk in 
full-curved needles. 

Placenta basin. 

Large floor basins under the patient's drainage. 

Usual sutures for peritoneum, etc. 

Scissors, straight and curved. 

Tape-sponges on rings — very many. 

Gauze to wall off. 

Hot saline. 

Sponges mounted on forceps, very many. 

Infant. 

Reception blanket. 

Mouth- wipes. 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 203 

Blow-outs. 

Cord instruments. 

Cord, tape, and binder. 

Basket. 

Hot and cold tubs. 

Eye solutions. 

Extra physician and nurse. 

Hot-water bottle. 

Pulmotor. 

Oxygen tank and catheter (intranasal). 

Note. — Be prepared for hysterectomy or ligation of 
Fallopian tubes. 

Herniotomy. 

Dissecting set. 

Hernia knife (Fig. 33). 

A piece of sterile tape 10 inches long to slip under the 
cord as a retractor. 

2 sharp 4-pronged retractors. 

2 blunt hooks. 

Artery clamps. 

Ligatures of catgut Nos. 2 and 3 plain. 

Sutures — (1) Deepest, kangaroo tendon on medium- 
sized, sharp, half-curved needles; (2) for sac, plain catgut 
No. 2 in medium-sized, full-curved needle; (3) silk or .silk 
gut for the skin. 

Needle-holder. 

Tape-sponges on rings, hot saline, towels, etc. 

Large gauze fluffs. 

Rubber tissue to protect dressing. 

6-inch bandages — (a) gauze, (b) muslin. For inguinal 
and femoral, etc., a spica is put on protected w r ith oiled 
silk cuffs and adhesive (Fig. 34). 

Nephrectomy, Lumbar Route, Nephrotomy, Etc. 

Dissecting set. 

Ligature carrier. 

Clamps. 

Aspirating syringe and needles (longest and largest). 

Sponge-holders. 



204 OPERATING ROOM 

Ligatures (rubber, heavy twisted silk, catgut No. 4). 

Set for rib-resection (costotome, bone hook, periosteal 
elevator). 

Compresses 4 by 16 inches and from four to eight 
thicknesses. 



Fig. 34. — Colostomy bag — receptacle for arti- 
Fig. 33. — Hernia ficial anus, soft rubber with belt adjusted to 
knife. left side. French pattern. 

2 red rubber drainage-tubes, | by 8 inches. 

Narrow gauze drains. 

Needle-holder. 

Sutures — silkworm-gut for outer wound in heavy full- 
curved needles; catgut Nq. 2 for the skin; chromic gut 
No. 2 for muscles; catgut plain Nos. 2 and 3 in long sharp 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 205 

full-curved needles, and small half-curved needles for the 
pelvis of the kidney. 

Accessories. — Patient lies on his abdomen on a kidney 
bag, inflated, with the diseased kidney the higher; instru- 
ments cannot lie flat on him; kidney bag under the loin 
of the sick side; give him a pillow and put his arms in a 
comfortable position to prevent paralysis. The nurses 




Fig. 35. — Sharp-pointed curved bistoury. 

should try this themselves. Surgeons may need foot- 
stools. To "deliver the kidney" means to bring it out 
through the cut with a "gush." All towels must be 
pinned or clamped. Be sure that the work is on the sick 
kidney (Figs. 35, 36). 




Fig. 36. — Probe-ended bistoury. 

Curettage. 

Specula (Sims and weighted). 

Vulsellum. 

Uterine sounds and probes. 

Uterine dressing forceps. 

Packer. 

Sponge forceps. 

Anatomic forceps. 

Straight scissors. 

Kelly pad. 

Towels. 

Vaginal sheet and triangles. 

Dilator. 



206 OPERATING ROOM 

Curets. 

Intra-uterine douche tip. 

Rubber tubing for douche tip. 

2 iodoform strips 1 inch wide. 
1 iodoform strip 3 inches wide. 
Pad, safety-pins, and T-binder. 

Douche of plain sterile water in irrigator at 120° F. 
Trachelorrhaphy. — Add to the above: 
1 long pair mouse-tooth forceps. 
Scalpel. 
Tenaculum. 
Artery clamps. 

Sharp scissors curved on the flat. 
Needle-holder. 
Cervix needles. 

5 sutures (silver, wire, and wire twister, chromic gut 
Nos. 2 and 3). 

Wire scissors, shield, and "counterpresser." 
Perineorrhaphy. — Add to above: 
Kelly's crooks (as retractors). 

3 vulsella. 

Special perineal needles. 

Antiseptic powder. 

Gauze packing for vagina. 

Silkworm-gut or chromic gut Nos. 2 or 3, or button, 
shot, or silver wire, and silk to carry it. 

Hemorrhoidectomy. — Ligation Method, — Local anes- 
thesia. 

Brinkerhoff's slide rectal speculum. 

Headlight or droplight. 

Pratt's bivalve speculum (to deliver hemorrhoidal tu- 
mors). 

4 Halstead's hemostats, crurved, 5 inches, to bite 
"spurters" or pull down tumors. 

1 pair scissors, curved on the flat, blunt, 6 inches (dis- 
secting tumors back to their base). 

1 single-toothed tissue forceps, 7 inches (for removing 
"tabs"). 



LIST OF INSTRUMENTS FOR CERTAIN OPERATIONS 207 

Tank package twisted silk, size 13, or catgut, to ligate. 

Cotton, gauze, " whistle" (tampon canula) made of 
rubber tube wound with gauze and greased copiously. 

Wipes, T-binder (male or female), rectal pads. 

Sponges on sponge forceps. 

Notes. — Three 25-minim hypodermic syringes of 2 per 
cent, cocain or novocain with 5 drops of adrenalin chlorid 
(1 : 1000) added to each. Sims position, nurse or orderly 
on side farthest from the doctor holds buttocks apart, 
sponges, etc. 

Operation on Fistula in Ano. 

Brinkerhoff slide speculum. 

Lights, etc., as above. 

Probes, flexible and plated. 

Grooved directors, flexible and plated. 

One probe-pointed grooved director. 

1 Wilm's plated angular director. 

Knives — 1 straight sharp pointed, 1 curved sharp 
pointed, 1 straight probe pointed, 1 curved probe pointed. 

4 Halstead's hemostats. 

1 single-toothed tissue forceps, 7 inches long. 

1 pair scissors, sharp straight, 10 inches long. 

1 pair scissors, curved sharp, 10 inches long. 

1 pair Allingham's rectal fistula scissors. 

1 curet. 

Ligatures for bleeders. 

Gauze, cotton, pads, binder, etc., as per Hemorrhoid- 
ectomy. 

Three hypodermic syringes, as above, for local anes- 
thesia. 

Hemorrhoidectomy. — Clamp and Cautery Method. 

Speculum. 

Pile clamp. 

Cautery. 

Mouse-tooth forceps. 

Artery forceps. 

Blunt dissecting scissors. 

Scissors curved on the flat. 



208 OPERATING ROOM 

Scalpel. 

Special "screw-crusher" clamp. 

Needle-holder. 

Needles — (1) Large surgical with catgut No. 3 to trans- 
fix large hemorrhoids; (2). straight for small ones. 

Sponge forceps. 

Catgut ligatures No. 2. 

Towel on cautery handle. 

Sponges. 

Sponge on string to plug rectum during work. 

Accessories. — Iodoform or aristol powder; tampon 
canula or "whistle" well lubricated; split compress; 
gauze; binder; vaselin; soapsuds for cleansing, saline to 
follow; rubber apron; Gant pads. 



CHAPTER XV 
NOMENCLATURE 

"Call a spade a spade.' ' 

Terms Created by the Workers of the Operating Room in Contra- 
distinction to the Terms Used in Surgical Diagnosis or Pathology. 

To the young nurse — Warning! Be hereby advised 
never to use any term relative to nursing (or anything 
else, for that matter) whose meaning you do not under- 
stand well enough to give a reasonable explanation to 
the surgeon who knows a great deal more than you do 
about it, or to the junior nurse who knows less, and has 
a way of asking very embarrassing questions. 

There are many pupils whose previous training in 
English was of the most circumscribed proportions (what 
is the English of one year in high school?) and yet, in a 
hospital, they come out boldly with long terms which 
they can neither define nor spell correctly. But this can 
be mastered, and *is no reason why they should not be 
used in their proper place. Some pupils with the limited 
vocabulary aforesaid pick up these words and play with 
them as with a new toy, reiterating them until others who 
. can speak English well are bored to death. Learn the 
derivation of all these terms, and employ them only 
when that will save time by being concise. The well- 
educated gentleman is master of many languages, but uses 
only the simplest Saxon. Plain, simple Saxon is much 
more forceful and figurative than words of classic origin. 

There are certain Latin and Greek roots, not many in 
all, that are used as a basis for all the terms describing 
the operations that are performed, and, added to the 
classic roots that name the different parts of the body, 

14 209 



210 OPERATING ROOM 

show at a glance the entire proportions of the work done. 
The name of the operation appears only about five times 
per case: 

(1) When it is posted in the office or the operating-room 
calendar. 

(2) When the supervisor drills the pupils who are to 
assist in the anatomy of the parts concerned so as to 
select the proper instruments and materials. 

(3) On the slip sent down to the ward briefly specify- 
ing the salient features of the whole affair for the imme- 
diate enlightenment of the nurse who is to take care of 
the ether patient. 

(4) On the chart in three places — (a) opposite the hour 
when it took place in the day's sequence of events; (6) on 
the patient's discharge slip; (c) and on the history sheet 
written up at full length by the intern. 

(5) And, lastly, in the register kept by the operating 
supervisor of all cases. 

Model of slip sent to ward with ether case: 

1. Date. 

2. Patient's name. 

3. Ward whence patient came. 

4. Operator. 

5. Operation. 

6. Anesthetic. 

7. Stimulation. 

8. Drainage. 

9. Condition. 

The word used to signify the disease or cause for opera- 
tion may be entirely different from that describing the 
process of cutting, sawing, or sewing; and, again, some- 
times a correct diagnosis cannot be made until the opera- 
tion is almost complete. Again, the same operation may 
be performed for two entirely different conditions. To 
illustrate the first, we all know what a cleft palate is, but 
the operation to repair it is called staphylorrhaphy. 
Second, an opacity of the lens of the eye is called cataract. 
The tense, hard condition of the eye due to certain glandu- 



NOMENCLATURE 211 

lar secretions being blocked at their proper outlet is called 
glaucoma. But both cataract and glaucoma are relieved 
by iridectomy. To distinguish carefully between these 
is a necessary feature in the supervisor's instruction; e. g., 
ectomy means cutting away entirely, while otomy means 
cutting into. In a different chapter, on Surgical Diag- 
nosis, the terms describing the pathologic conditions 
causing operation are given. If one is asked what was 
the nature of the operation, she should bravely say, "He 
had his gall-bladder removed" if she cannot remember 
"cholecystectomy, " but she should not say "cholecysti- 
tis" and miss the mark. To make the names of all opera- 
tions place the name of the anatomic part first, of Latin 
or Greek derivation, and the foreign root, describing the 
work to be done, last. It is better for pupils to know a 
few classic roots and "make their own terms" than to 
swallow unsearched, unprobed, and unknown a bowlful 
of ready-made terms. Knowing the why and the where- 
fore of everything warms the cockles of the heart in an 
otherwise dull existence. 

Greek words are mostly used for the thing done, 
whether cutting out, or sewing up, or cutting into for 
drainage, and Latin, generally but not always, for the 
anatomic part operated on. In making up new words 
it is well to remember the rule: Double the final con- 
sonant after a short vowel, as benefit, benefitted; label, 
labelling. When one has built up a new term and re- 
ceived the supervisor's 0. K. for pronunciation and spell- 
ing, the whole term should be written ten times or so for 
practice. This is one feature that makes the operating- 
room pupils the despair and envy of the remainder of their 
class in recitation. 

Adeno, relating to glands — of the neck, axilla, etc. 

Chole, relating to bile. 

Colo, pertaining to the colon, part of the large intestine. 

Colpo, relating to the vagina; there are few terms begin- 
ning with vag to denote any operation. 

Cranium, the skull, or bony covering, not the brain. 



212 OPERATING ROOM 

Gastro, pertaining to the stomach. 

Hysteron, the uterus. 

Jejurij relating to the second part of the small in- 
testine. 

Lamina, a plate or layer (posterior vertebral arch). 

Nephron, the kidney. 

Odphoron, the part bearing the egg (Greek, the ovary). 
Note the pronunciation and spelling, also the dieresis which 
is used to divide two vowels that would otherwise be pro- 
nounced together as a diphthong (oo is pronounced like oa 
in oasis). 

Ophthalmo, relating to the eye. 

Orchi, relating to the testicle (genito-urinary ) . 

Osteo, bone (Latin, os, ossa). There are, of course, 
many bones and many varieties of operations on bones, 
the particular part diseased being specified — e. g., oste- 
otomy, division of a bone, but which one must be speci- 
fied. 

Ot, pertaining to the ear. 

Proct, relating to the rectum. 

Prostat, relating to the prostate gland (genito-urinary). 

Rhino, pertaining to the nose. 

Salpinx, the tube. 

Spermato, relating to the semen. 

Tars, pertaining to the instep. 

Ten, pertaining to a tendon (in the eye, wrist, etc.). 

Trachelo, relating to the cervix or neck of the uterus. 
There is no word beginning with cervi to denote an opera- 
tion on the cervix. 

Tracheo, pertaining to the windpipe only. 

Uretero, relating to the two pipes or tubes from the 
kidneys to the bladder. 

Urethr, relating to the one canal from the bladder to 
the outside. 

Vas, the 'sperm duct. 

The few classic words describing the work done, or 
the mechanical process in which instruments are em- 
ployed, may each be added to any and every one of these, 



NOMENCLATURE 213 

making a now far from bewildering but very extensive 
vocabulary. To have three new words radiating from 
each of the above terms — gastrostomy, gastrotomy, gas- 
trectomy — means quite a variety in operating-room ex- 
perience also. The clever nurse reckons her work up as 
follows: "I have scrubbed for three appendices, one 
mastoid, two hernias, and one gastrostomy already, " or 
again, "I'm nearly through my service and I haven't had 
an iridectomy or a hysterectomy." 

-ectomy (Greek, cutting off), a complete removal of a 
part. 

-orrhaphy (Greek, suture), a sewing up. 

-ostomy (Greek, stoma, a mouth), making a new opening 
out of an organ; usually a new path to pass the intestinal 
contents along in order to get by an obstacle, usually a 
malignant growth. 

-otomy (Greek, to cut), a cutting into for drainage. 

-plasty (Greek, meaning form or shape), cutting and 
trimming off; straightening and smoothing for some pur- 
pose. 

Sometimes operations are named after the first great 
pioneer who performed them, but the latest authorities 
agree that proper names should be banished both in 
anatomy and surgery, therefore only one of the names 
of those great surgeons will be mentioned here, much as 
one would willingly add to their laurels. A strong effort 
should be unitedly made to abolish this foolish, confus- 
ing custom. In anatomy, the parts should be named 
according to where they are and what they do. In 
surgery, the operation should be named according to the 
part affected and the work effected. Simple, concise 
terms, founded on the primary studies of the medical 
student, will bring the surgeon into closer touch with 
the general practitioners who herd the cases in his direc- 
tion, and with the nurses who are his earnest hand- 
maidens. 

There are many special terms used in the operating 
room relating to action rather than to passive conditions, 



214 OPERATING ROOM 

which, therefore, find a more fitting place in this than in 
the chapter on Surgical Diagnosis. There are also cer- 
tain words formed according to the rules above given 
whose pronunciation and spelling are unique. Other 
names are misnomers, due to slipshod methods. Some 
names are compounded, part upon part, on account of the 
masterful efforts made by some of these modern, radical 
"trouble men," as they call the mechanics in the garages, 
who can fix anything that is wrong in an automobile. 
Some of the words listed are of diagnoses often confused 
with operations. The number is far from complete, and 
on the blank pages following should be inserted all the 
new words each nurse hears, with its definition. Some 
require the insertion of an extra vowel for smoothness of 
sound. 

Adenoids. Hypertrophied tissue in the nasopharynx. 
Note also the spelling of "pharynx"; y is the same in value 
and pronunciation as i; "rynx" = rinks. Pronounce like 
far inks. 

Anastomosis means a joining, end-to-end, as of two 
pieces of gut. 

Bloodless operation. Usually the name given to the 
method employed to straighten the limbs in congenital 
hip-disease. There is no external wound; the bones are 
broken by manual force, without instruments, and the 
child immobilized in a "frog" of plaster of Paris, the posi- 
tion being "overcorrected" or exaggeratedly changed. 

Bone-grafting or Bone inlay. A quite recent discovery; 
splicing an old, diseased bone with a sound piece; taken 
usually from the tibia to repair a tuberculous spine. 

Bone-plating. A metal plate (the sizes vary) is screwed 
in place with steel screw-nails to join two ends of broken 
bone. 

Burns or scars from other accidents are atoned for by 
skin-grafting — a plastic operation. 

Cesarean section. Note the spelling (obstetric term). 

Clamp and cautery. Slipshod name for a certain opera- 
tion to remove hemorrhoids. 



NOMENCLATURE 215 

Coccygedomy. Pronounce kok-sig-jec-tomy. Note the 
spelling; a very simple operation, as the name shows. 

Craniotomy. Obstetric term. 

D. and C. A cloak for abortions that are not neces- 
sary sometimes. 

Dilatation. "Dilation" is quite as correct. 

Excise. To cut off, to remove, especially what is seated 
near the surface. 

Extirpate. To cut away or remove what is deep seated. 

Gastro-enter ostomy. An opening from the stomach into 
the intestine, usually the jejunum, to get past some ob- 
struction above the latter; an illustration of a compound 
word. 

Immobilize. To fix, to render motionless, with a splint, 
a plaster cast, or sand-bags. 

Incise. To cut into, as into a boil, for drainage. 

Iridectomy. A misnomer; should be qualified by the 
term "partial" or "incomplete." The whole iris is not 
removed unless the rest of the eye goes with it. A tiny 
piece only is cut out, leaving a black patch which is a con- 
tinuation of the pupil, the whole resembling and some- 
times called a "keyhole." 

Jejunojejunostomy. Sewing two parts of the same gut 
together and making a mouth afterward at the point of 
junction so as to catch any portion of the intestinal con- 
tents lurking in the "vicious circle," like a plumber's trap, 
left above after a gastrojejunostomy, as can easily be 
seen by a drawing. 

Kraske. The name of the surgeon who relieved cancer 
of the rectum by removing the coccyx and part of the 
sacrum to form a new opening above the malignant 
growth. 

Ligation. A term for one kind of hemorrhoid opera- 
tion; tying off the dilated vessels and excising. 

Myringotomy. Cutting through the ear drum for 
drainage. 

Needling. An operation on the eye, done as a sec- 
ondary to the primary iridectomy; lacerating a cataract 



216 OPERATING ROOM 

with a needle to afford entrance to the aqueous humor 
and cause absorption of the lens. 

(Esophagectomy , (Esophagotomy. Note the spelling. 

Panhysterectomy. Extirpation of the whole uterus, 
in distinction from hysterosalpingo-oophorectomy (three 
o's together), which means the removal of uterus, tubes, 
and ovaries. 

Plastic. Sewing, trimming off, etc., for repair and 
cosmetic effect. 

Pyloroplasty. Sewing and cutting around the pylorus. 

Resection. Wrongly used, to mean taking a piece of 
rib out, to produce drainage for empyema. 

Splenectomy. It is interesting to know that man can 
live after certain organs like the spleen have been taken 
out. 

Staphylorrhaphy. Operation for cleft palate. 

Tonsillectomy. The new method of removing the 
whole tonsil by snaring it at its base. 

Tonsillotomy. Old method of cutting off the top of a 
tonsil. 

Trephine or Trepan. Sawing into the skull, generally in 
three rings or disks, to break off the small bridges remain- 
ing without much jar to the patient. 



CHAPTER XVI 

LINEN OF THE OPERATING ROOM 

It is quite easy to calculate how much linen of every 
kind is needed for an operating room. This depends on — 

(1) The kinds of cases and the articles each requires. 

(2) The number of cases per day. 

(3) The number of nurses and the amount of time at 
their disposal to refold, put up in covers, and sterilize. 

(4) Fractional sterilization. 

(5) The speed at which the laundry operates for the 
surgical service. 

(6) A possibility of illness among the nurses. 

(7) A possibility of breakdown or repairs in the steril- 
izers. 

(8) An abnormal rush in the service at certain seasons. 
To start with a great deal of linen is not going to wear 

it out faster, and it is a great gain to the supervisor's 
anxious mind. But she should have an inventory of all, 
and a perfect system of exchange in cooperation with the 
central linen room, which exchanges at its own pleasure 
for the rest of the house, but at her pleasure for her service. 
Patching all holes is absolutely imperative. A steril- 
ized towel is not of any use if it has a hole in it. But 
patches are no disgrace and offer no disadvantage. On 
the contrary, to put on patches and to use patched goods 
are essential in a nurse's training. Whether the nurse 
does this as a part of her operating-room experience, or 
in her course on housekeeping under the matron, is a 
matter of indifference so long as she does it some time. 
Uniformity is of great advantage both for appearance 
and speed of work. It is pleasant to see some harmony 
between the color of walls, table, towels, and stains in 

217 



218 . OPERATING ROOM 

carbolic acid or bichlorid (as warnings for poisons). If 
towels were originally a red check, and it is desired to 
change to a blue check, give all the red checks to the 
wards and buy the blue outright. 

White linen is preferable for gowns and caps, since it 
always looks so snowy. There is no good excuse for the 
very bad color of most linen, since the reason is a bad 
one. Operating-room linen should be bleached in the sun, 
especially in slack times, being dried, then sprinkled down, 
and dried again many times, as the Dutch women do. 
But it is mostly dried in the driers and never gets a whiff 
of fresh air, soon becoming stuffy and dark. There are 
many bleaches put on the market and many washing fluids 
patented which are supposed to whiten linen without 
labor, but that sort always eats away the goods. A 
gown or uniform frays in six months or less if laundered 
with bleaches. By having an extra lot of gowns and 
bleaching them with sunshine money is saved in large 
quantities. A good system for operating-room linen 
laundering is as follows: 

(1) The linen is sent down with all clots and stains 
soaked out in cold water and put then into the machines. 

(2) Rinse cold twenty minutes. 

(3) Warm water and soap twenty minutes; wash by 
machinery. 

(4) Warm rinse ten minutes. 

(5) Hot water and soap thirty minutes; wash by 
machinery. 

(6) Hot rinse five minutes. 

(7) Hot rinse five minutes. 

(8) Hot water and 4 ounces of acetic acid to the 
machine, ten minutes. 

(9) Cold water, add the blue, ten minutes. 

Most laundries neglect rinsing. Frequent rinsings 
clear linen better than anything else. Wyandotte soda 
with chipped soap precipitates lime salts. These are 
bought by the barrel. Anilin blue (No. 90) in 1-pound 
cans is purchased for the coloring. Flannel covers for 



LINEN OF THE OPERATING ROOM 219 

masks should be washed with green wool soap and rinsed 
thoroughly in water with a little glycerin added, then 
hung in the fresh air with the stripes vertical. Gowns fre- 
quently lose their tapes, and it is not to be wondered at 
when one sees the inside of a washing-machine; they 
should, therefore, be washed in open net bags, similar to 
those for nurses' handkerchiefs, to prevent tearing or loss. 
Dome fasteners are better than buttons. These little 
details of repair should be done by the nurses who scan 
the articles closely as they prepare them for refolding. 
Scultetus binders, straight abdominal, and breast binders 
must be well ironed. The nurses' course in the hospital 
is not complete without having had one month under a 
competent housekeeper, where they learn all these 
things, with an eye to future positions of their own, but 
the present benefit to their training-school and hospital 
is a sympathy with the office in its enormous outlay, with 
those humble employees who labor for them, and a de- 
termination not *to be extravagant. 

Every operating room should have its book of measures 
and patterns with samples of goods and lists of firms fur- 
nishing these, their prices, discounts, and length of time 
in delivering. There should be a set of stencils for mark- 
ing goods, whether those made by 'hand in the workroom 
or grown dim with frequent laundering. The study of 
standards of weight in various kinds of cloth, such as 
Ca'nton flannel, unbleached muslin, etc., and thread 
gauges in gauze forms interesting and valuable work to 
the pupil. 

SPECIAL ARTICLES 

Men's T-binders are not like those for women. The 
perineal strap is split in two, so as to come up at each 
side of the genitals. The edges are all carefully turned 
in and stitched, and at the upper end of the split a crow's 
foot stitched in to prevent a tear. The sizes should vary 
according to the 'waist measure, since men vary so in 
stature and girth. 

Men should wear suspensories if to be confined in bed 



220 OPERATING ROOM 

flat on their back for any length of time. These can be 
bought, assorted sizes, and put on in the operating room 
at once after operation. If not purchased wholesale at a 
low rate, they can be jnade, by the aid of scissors and a few 
safety-pins, out of a couple of yards of 4-inch muslin 
bandage. If not applied, the long-continued horizontal 
position causes certain inflammation. 

Laparotomy gowns and stockings are made of thick 
soft Canton flannel. The gowns are opened at the back 
with tapes, not buttons, and the stockings go with them in 
sets. Each set should be folded so as to show its mark- — 
A. B. Hospital, lap. gown and sox, 4 ft. 6 in. — 54 inches 
being the total length of the set, it can easily be adjusted 
to the height of the patients. The stockings should not 
be folded separate from the gowns. Just as soon as the 
case is over, a set which has been warming in the blanket 
warmer or, failing that, on the radiator should be put on 
instead of the one already wet with perspiration. 

Scultetus binders are made of Canton flannel. Noth- 
ing else will do. The piece for the back should be for an 
adult, from 12 to 15 inches long and 7 to 9 inches wide, 
not allowing for the making. It must be double, there- 
fore is most easily made by taking a piece 24 inches long 
and folding it once crosswise, and basting it along the 
edges and down the center to keep it straight while 
setting in the "tails." There should be ten tails, five on 
each side, overlapping about 1 whole inch. The tails 
are cut, not torn, and are overcast finely, not hemmed, on 
all edges by hand. The fold in the back piece, as in 
all binders, indicates the bottom. The patient must not 
lie on a seam. Five tails are set in on one side with pins, 
extending inside the back piece about f inch, for security 
in the braiding effect afterward. The basted edges of the 
back piece are then turned in and the whole basted 
through, taking care to remove all pins. The tails 
must all overlap an equal amount and in the same direc- 
tion as well as in the same manner. The opposite side is 
done similarly, taking care that the tails will be set in in 



LINEN OF THE OPERATING ROOM 221 

exactly the same way, so that both sides will look alike. 
Taking up the binder both sides should overlap down- 
wardly or both upwardly, otherwise it never can be put on 
properly. It takes a long time to make one Scultetus 
binder, and if the nurses do it in classes they will never 
be guilty of cutting one to let a drainage-tube through. 
In one instance it took a class of six nurses one hour to 
make one Scultetus binder as a lesson. As to the width of 
the tails, for a binder of 12 inches depth each of the five 
tails should be 4 inches wide and overlap 1 inch each. 
As to the length of the tails, they should come from the 
back piece on one side, across the abdomen and back to 
the other side of it, that is, once the measure of the 
patient's girth less the width of the back piece. If a 
patient is 40 inches around the abdomen, and we make 
a back piece 8 inches wide when finished, the tails should 
all be 32 inches long (not counting the making). Sculte- 
tus binders should be made in all sizes, first measuring a 
few patients with thick cotton-pads and piles of gauze 
dressings to get them correct. 

A maternity breast binder with a plain sleeve added 
makes an ideal dressing for a breast amputation. Make 
a sleeve of the ordinary men's coatsleeve st}de of double 
unbleached muslin, but open it on the outer surface of 
the arm in a line running from the ring finger to the tip 
of the acromion process (when the palm of the hand is 
downward). This opening is closed with tapes, four on 
each side, about 8 inches long. It corresponds with the 
opening at the shoulder of the breast binder, whose flaps 
extend about 1 inch past the sleeve on each side. The 
dressings of the axilla are easily kept in place and the 
binder may be reversed. The sleeve need not extend be- 
low the elbow. (See Figs. 24 and 25.) 

Caps should be of light weight material, but firm. If 
very slightly starched rather thin material will do, espe- 
cially in summer. The pill-box type fits so closely that 
perspiration flows more freely, whereas a tall wedge cap 
keeps the head rather cooler (Fig. 37). 



222 



OPERATING ROOM 



Masks should be made of heavy dimity, but nothing 
heavier than that, since even the sheerest is intensely un- 
comfortable. 

Laparotomy sheets should have an opening not more 
than 10 inches long and 6 inches wide, making at any 





Fig. 37. — A becoming cap to either doctor or nurse. 



time required about a 16-inch ellipse; for example, in 
cesarean section. The sheet should be long and wide 
enough to extend over the body of a very fat patient and 
reach down not farther than 3 inches below the surface 
of the table. If a patient is very tall; an extension, in 
the shape of a table cover, may be used for the feet. 



LINEN OF THE OPERATING ROOM 



223 



Laparotomy sheets should be of assorted sizes, with the 
exception of those for small babies, when a large towel 
may be slit in the manner described. 

Vaginal sheets of the style shown in the illustration 
(Fig. 38) are abundantly required, and can be easily put 




Fig. 38. — Vaginal sheet. 



on or removed after the vaginal work is done. The sheet 
goes on over the sterile triangles which cover the stirrups. 
This is so secure that it makes a sterile table cover over 
the abdomen for instruments, and is much less confusing 
than a number of towels and clamps. 



224 



OPERATING ROOM 



Triangles and sheet are folded in sets in such a manner 




> 
o 






of. 



c3 



o o 



CD 

> 

c 
o 

G 
O 

a 



'o 

Oh 
W. 

<D 

B 
m 

i 

as 

CO 

s 



CD 



that the two former, each into half a square, fit together 
on top of the square sheet and make a very good-looking 



LINEN OF THE OPERATING ROOM 225 

package. A triangle is an unbleached muslin cone to 
cover the leg and thigh. 

For tubes of packing it is a waste of time to roll them 
tightly in a wayward square cover. Make a long narrow 
double tubular bag (Fig. 39, 6), with a drawstring at the 
neck, and put the tube in it. Of these there should be 
many, one for each tube in the sterile stock, one clean 
extra for each, one being laundered, etc. All dressing- 
covers, including these bags, should be very frequently 
laundered and bleached to counteract the burning they 
get in the sterilizers. 

Gown Covers. — Again, it is a pity to ask a nurse to tug 
with gowns (Fig. 39, a). Rather provide covers specially 
for the gowns. Each should have a double cover with a 
flap and boxed edges, somewhat resembling a square 
cushion, and dome fasteners. This saves much time and 
vexation. These are particularly nice for a private 
physician's kit. Glove envelopes are referred to in Care of 
Rubber Gloves, chapter on Formulae and Directions 
(Fig. 39, d). 

Folding Linen. — There are two methods of folding 
linen. By one the article is taken at its full length and 
folded often enough to be a convenient width — a towel 
once, a gown twice — then simply plaited, so that it may 
drop to its full length by only gently lifting one edge 
(Fig. 40). When a doctor is putting on a gown it is pre- 
sented to him with the collar uppermost. He takes it by 
the collar in a clear space in the room, and as he raises it 
it drops its full length. But the trouble with this 
method also arises from that very feature. Things 
opening too easily might be easily contaminated. The 
one counterbalances the other. The second method is to 
fold the article from its ends toward its center so as to 
control it perfectly. 

To fold a towel 24 by 30 inches or of similar proportions, 
lay k-o over on a-e, pressing the fold f-j firmly. Bring 
the double edges a-k to /and e-o toj to the center c-m to h, 
almost, but not quite, to prevent a hump. Now fold from 

15 



226 



OPERATING ROOM 



b-l to g and d-n to i to the center again. Then fold to- 
gether. In opening this towel hold the folds at d and at 6 
in the right and left hands respectively, between the fore- 
finger and second finger. Hold the points at a and e 
between forefinger and thumb also. Keep the two 
thumbs close together and the whole towel compressed . 
until, having wedged a way between two assistants, one 
has space close beside the area to open the towel out sud- 




Fig. 40. — Gown and towel plaited in one direction — opening too 
easily with one movement. 

denly like a fan and lay it in situ. This method keeps the 
whole bottom edge, k-l-m-n-o, securely fastened be- 
tween the thumbs until needed (Fig. 41). 

In folding gowns, hold by the under arm seams and let 
drop longitudinally into four thicknesses. The nurse 
keeps the under arm sides next to her and makes them the 
straight edge. The sleeves are turned (together) at a 
sharp right angle to this line, straight across the gown, and 



LINEN OF THE Ol'EKATINU ROOM 



227 



when they reach the opposite edge sharply folded back on 
themselves, perfectly flat and square. Do not bring the 
sleeves down along the body of the gown. Turn in tapes 
into the inner part of the openings on the farther edge. 
Fold from the collar and the bottom in almost to the cen- 
ter. By leaving 1 inch in the middle the folds lie flatter. 
By applying great firmness and long, steady strokes even 
linen that is rough dried may be made quite beautiful. 
A nurse's hands ought to be as good as a mangle. All 
these articles should be laundry mangled, but binders are 



-/ 



h e d e. 


9 


h 


i 


J 


l 


m 


71 






Fig. 41. 



ironed. However, the laundresses do not fold for the 
sterilizing. The method of folding should be uniform 
throughout the hospital. If large sheets and blankets 
are folded in and in, they present a handsome appearance, 
since it hides any dissimilarity in stripes, while things of 
varying sizes that have to be used for the same purpose 
can be approximated to look the same, but laparotomy 
sheets and gowns must be folded in their assorted sizes 
to be selected quickly. 

There should be a large stock of bags in the workroom 



228 OPERATING ROOM 

for dressings, both sterile and unsterile, ward, reserve, 
and operating-room supplies. These may be of stout 
unbleached muslin, carefully stencilled and very fre- 
quently laundered. 

Blankets. — The top stretcher blankets should be crim- 
son, being much more cheerful and preventing any sight 
of blood. They should be of wool only, and long enough 
to reach from the crown of the head to the sole of the foot. 
When a nurse is preparing a stretcher, if her patient is very 
tall she should lay an extra blanket from the center down 
to have enough for covering him. In every case the 
blankets should be laid on the stretcher first, then the 
binder, then the patient, then the lower blankets are 
brought up over him in every direction, particularly down 
around the shoulders . and up over the feet, then new 
blankets over all. It is wrong to weight a patient down 
with many cotton "blankets?" because they are worse 
than useless. A couple of all wool blankets contain more 
heat than six cotton ones; but they should be of a suit- 
able color, fawn or reel, and protected very carefully from 
dirt, so as not to be in the laundry all the time. There 
should always be some kept in the blanket warmer, to- 
gether with gowns and stockings. When requiring wash- 
ing the} r should be first looked over by the supervisor and 
marked with a slip signed by her. The laundress should 
hold up all blankets not so marked. This makes the 
nurses careful about handling woolen goods recklessly. 
Small woolen masks, etc., should be boiled to prevent 
the spread of disease. 

Stains must be removed before linen is sent to be 
washed. If so, the furtive attempts to use bleaches are 
headed off and the pupils trained in good housekeeping. 
Iodin is removed by alcohol or ammonia. Rust on metal 
is removed by Sapolio, on enamel by a weak solution of 
oxalic acid or Sapolio, and on white goods by (1) cream of 
tartar paste and sunshine or (2) lemon-juice and salt. 
Vaselin and other greases disappear with the application 
of ether, but it is very expensive, and the spots should not 



LINEN OF THE OPERATING! ROOM 229 

be made in the first place. Bichlorid makes a gray stain, 
removable only by Javelle water or Labarraque's solution, 
the latter being diluted 1 to 6. 

Labarrague 's Solution. — Sodium carbonate (washing- 
soda), 10 parts; chlorid of lime, 8 parts; water, 100 parts. 

Linen for Isolated Cases or Dirty Dressings. — Large 
old linen ends can be folded and sterilized as towels for 
isolation or dressings that stain. This saves waiting for 
the long period of disinfecting. Do not send good oper- 
ating-room linen out of the main room for two reasons: 
(1) It takes a long time to get it back; (2) by some mishap 
it may not be disinfected, and, coming to that common 
center, redistribute contagion all through the hospital. 
Small pieces should be squared off and folded for dressings 
for burns, for which there is nothing better. Gauze must 
not be put on a burn. It allows the ointments to pass 
through, then when removed it tears off the new granu- 
lations. 

Measures.— A special section must be kept in the book 
of measures and patterns as to the sizes and lengths and 
materials for surgeons' suits, to be sent to the tailoring 
firms from whom they are ordered. No man wants to 
wear trousers made by the ladies' auxiliary. The suits 
should all come from a well-known hospital outfitter, 
thus saving time and money. The addresses of firms, 
samples of goods, shrunken and unshrunken, and the 
cost must be carefully entered. It is the head nurse's 
duty to call the nurses' attention to all these details in 
regard to the care of goods and devotion to the needs of 
the surgeons; to train them for holding similar responsible 
positions. Goods should be ordered about twice a year 
to form a large enough supply and to save the payment of 
too frequent freight bills. A strong plea is made herein 
for the nurses' comfort, so as to produce efficiency and 
content. Their gowns should be of assorted sizes and 
with well-fitting neck and sleeves, so as to fit all statures. 
A sloppy gown is not aseptic. 



CHAPTER XVII 

BUYING FOR THE OPERATING ROOM 

Things not to buy are most important in a hospital or 
private home. Nothing should be bought just because 
it is inexpensive. It may never be needed. Nothing 
should be bought at the request of only one person; the 
virtues of the article must be demonstrated to the ap- 
proval of all. Articles for the operating room should not 
be out of proportion to those of the rest of the hospital, 
whether it be ward, dining-room, or laundry, either in 
number, quality, or cost. Glaring colors, fads in styles, 
and designs of towelling that are not continuously uniform, 
so as to be known always instantly by sight as "0. R.," 
must not be purchased. Cheaply made goods have infe- 
rior dyes, and these, in turn, not being fast, ruin more 
valuable garments; for example, a whole set of doctors' 
suits, trousers, and jackets were made pink by the colors 
running in some cheap new towels in one metropolitan 
hospital. All purchases should be made by or at the will 
and choice of the committee on surgical affairs. Time 
should be taken by the forelock, and samples tried out 
long before the actual need to purchase. 

These various difficulties can rarely be well met by 
one person. The superintendent, not actually engaged 
in nursing, does not know how certain goods operate. 
The operating-room nurse knows where they fail, but 
has not time to weigh, count threads, meet several sales- 
men on one class of goods, or write for samples and price 
lists. A "buyer/' so-called, cannot buy on his own 
first-hand information. He must collect statistics from 
the house and from his own bills to satisfy an exacting 
superintendent. In most cases the buyer is so busy 

230 



BUYING FOR THE OPERATING ROOM 231 

justifying his own existence that he puts in an inferior 
class of goods or too small a quantity, to the hampering 
and unhappiness of the workers. Then he cheerfully 
asks for an increase of salary, to utilize the margin he 
made, where it can do the greatest good to the greatest 
possible number — Number One. 

For all hospitals the simplest solution for the problem 
of buying is to become a member of that ingenious pur- 
chasing body, reaching from America to China, and 
capable of buying anything from drinking straws to dicta- 
phones, called the Hospital Bureau of Standards and 
Supplies, which is a club consisting of representatives 
from the largest and best equipped charitable institutions 
who have joined, with a fair membership fee, to support 
the actual buyers on salary, and who can then not only 
secure goods at a big discount from the wholesale firms, 
but have no anxiety about selection or delivery. They 
place their orders at the head office of the association, 
whose buyers at once send what they wish from the 
supply houses of the wholesale dealers with whom this 
bureau has fixed yearly agreements relating to that kind 
of goods. It is really a very extensive mail-order business. 
But it is not conducted for the profit of one individual. 
Hospitals are not money making concerns. These buyers 
must weigh all goods, taste all tea, coffee, sugar, etc., 
count the threads per inch in gauze or wool with a magni- 
fying glass if necessary, inspect cotton under the micro- 
scope, test the joints, valves, and bars in all plumbing 
apparatus, and only buy in houses whose goods meet the 
proper specifications. Goods are delivered very quickly 
and perfect satisfaction is guaranteed. This eliminates at 
least one salary in institutions of some size, and in the 
small hospital releases the superintendent to attend to 
the real superintending, of which buying should not be 
the only duty performed, otherwise certain basic prin- 
ciples must be observed in buying. Good goods produce 
efficiency in the care of the patient, but they must be 
strictly accounted for in placing, number, length of use, 



232 OPERATING ROOM 

and suitability. Buying a large quantity prevents ex- 
pense in freight and causes a feeling of security, while 
the goods are not wearing out. The responsibility of 
caring for the stock in bulk must be placed on very few, 
not only to keep it in order, but to distribute it weekly. 
Trade names have been paid for twice over. "Hexa- 
methylenamin" is bought very cheaply and used ex- 
actly as "urotropin" used to be; "thymol iodid" performs 
the same duties as "aristol," but is much cheaper. But 
a drug must not be bought and used this way until it 
responds to tests correctly. When buying certain articles 
on requisition from the operating room every feature 
must be described — e. g. } a jar for saline infusion must 
be graduated to 750 c.c, beginning at the top with ex., 
or, again, the length, style, material, eyes, stylet, bevelled 
tip of lumbar puncture needles must all be specified. 

Whisky and brandy should be of the best quality and 
then kept under lock and key, whether in bulk or on the 
wards. Hospital whisky, as a rule, is a joke for its uni- 
versal badness, unfit for both mouth and hypodermic 
medication. 

Alcohol may be bought at a very low cost in its dena- 
tured state if the proper forms are executed. The 
president of the Board of Governors must sign a bond 
for $5000 for each barrel of alcohol kept in stock con- 
tinuously by the institution as a guarantee that its use is 
confined to surgical, nursing, and pathologic ends. Were 
any one with evil intent to drink or otherwise depart from 
the legal uses of this liquid the president would have to 
forfeit this sum. An account, therefore, is kept of the 
use of all of it, and the care of it is left to a very con- 
scientious official, who keeps it well safeguarded for the 
president's honor. When the liquid is being ordered an 
affidavit is taken by the superintendent and president to 
the effect that its use has been honest. For use following 
carbolic acid as a cautery, however, alcohol must be used 
in its pum, not denatured, state, on the stump of the 
appendix. 



BUYING FOR THE OPERATING ROOM 233 

As to catgut, if the committee on surgical affairs were 
to visit and make comparisons of the various plants or 
laboratories where it is made wholesale they would be- 
come impressed with the folly of trying to do it them- 
selves and the justness of the prices imposed. Possibly 
they could also detect differences between the materials 
and preparation of these various firms such as would 
warrant the difference in prices; at any rate, in these days 
of keen competition, when every manufacturer knows the 
secrets, initial cost, and overhead expenses of his rivals, 
it cannot be disputed that when there is five cents' reduc- 
tion in the price there is five cents' reduction in the value. 
It is not necessary to pay only for a name, but when a 
name means confidence and merit it is wise to procure the 
best. Surgeons who thoroughly identify themselves 
with the highest interests of a hospital are economic of 
catgut. Their sutures are uniform for certain purposes. 
It is then easy to buy various lengths of catgut, done up 
in separate tubes for various purposes. 

Emergency Orders. — In a crisis that could not be fore- 
seen one is justified in ordering by messenger, special 
delivery, parcel post, or express; but for all that can be 
foreseen, freight is suitable and cheap, boat transporta- 
tion being again less expensive than the railroads. 

Important supplies that concern the actual knack or 
handicraft of a surgeon should be bought by the com- 
mittee on instruments with grave deliberation, not by 
the superintendent of nurses or the office, who have never 
fitted them to the hollow of their hand for hours in the 
greatest crisis of a patient's life. 



CHAPTER XVIII 

MINOR WORK IN THE OPERATING ROOM 
OR BASED ON ITS TECHNIC 

I. INTRAVENOUS INFUSION 

Intravenous infusions usually strike terror into the 
heart of a new nurse because she attributes the shocked 
expression worn by the staff on account of the patient's 
danger to some frightfulness in the treatment itself. 
Then she grows nervous and makes mistakes. One should 
be glad that such wonderful results can be accomplished 
by so simple a thing. But the same set of people never 
meet a second time to give an infusion, and the nurse, 
being the one that "belongs," must know her part thor- 
oughly and do her duty. When the patient is in shock 
from hemorrhage or from amputation of some organ or 
limb, infusion is resorted to as a stimulant, but properly 
never during sl hemorrhage, only after the vessels are 
securely tied off and the bleeding checked. Normal 
saline, containing just as much salt as the blood, is 
thrown into the vein to give the heart enough fluid to 
pump on until the patient can manufacture more blood. 
It is like the process of priming a pump that has gone 
dry, w T hose valves resemble those in the heart. The infu- 
sion is given in a vein to produce the quickest effect on 
the heart, and it is the arm that is usually chosen, being 
nearest the heart. The technic is universally the same, 
though the instruments ma}" vary somewhat. A tourni- 
quet is put on the upper third of the humerus between 
the heart and the seat of incision. Nurses should get the 
habit, when bathing patients, of observing the size, color, 
and position of the superficial vessels. As a rule, the 

234 



MINOR WORK IN THE OPERATING ROOM 235 

median basilic vein is selected in the left arm, since the 
operator is proceeding with the major work on the right. 
If for any reason it is not possible to use the arm, the 
ankle is resorted to, where the veins stand out promi- 
nently over the malleoli. In a patient's room either arm 
may be chosen, depending on the size of the veins. The 
tourniquet causes dilatation of the superficial vessels, 
but must not be so tight that it can cut off the deeper 
arterial circulation. If the arterial supply were cut off 
the lower arm would be pale and bloodless. It is a good 
condition, therefore, to find the arm darkened with an 
excess of venous blood, which cannot get back to be 
oxygenated in the lungs, all the portion between the 
tourniquet and the point of incision being now very 
coagulable, must bleed back before the saline is injected, 
which, otherwise, would drive that thick impure mass 
back toward the heart, possibly causing a, plugging of the 
circulation by a clot. Such a clot is called a thrombus, 
and the condition of being so plugged is called thrombosis. 
A few snug turns of an Esmarch bandage are sufficient. 
A long rubber tube about as thick as a rectal tube, with 
its ends crossed over the vein and held secure by an 
artery clamp, makes a good hurry-up tourniquet. A 
muslin bandage may suffice. 

The area to be incised is painted with iodin and sterile 
towels laid above and below. The doctor performing 
the infusion should wear cap and gown, since bad effects 
may occur from the dropping of dandruff in such a 
wound. 

The skin is incised about 1 inch by a scalpel. With 
the blunt end and a thumb forceps the sheath of the 
vein is dissected away and the swollen blue vessel ex- 
posed. A grooved director is run under it to keep it 
elevated, then two catgut ligatures, one above and one 
below the coming incision, each tied loosely once. Then 
the distal ligature (measuring from the heart) is tied tightly 
to prevent any more venous blood from welling out into 
the wound. All the blood that previously travelled back 



236 



OPERATING ROOM 



by way of that vessel to the heart must now forever take 
one of the side channels to reach its destination. (See 
Anastomosis in any text-book on anatomy in the chapter 
on Circulation of the Blood.) The vein is now incised, 
and by force of gravity the thick dark mass above drips 
back through the canula (Fig. 42), now inserted to keep 
the vein open, attached to the fine rubber tubing of the 
set, fitting it exactly. The tourniquet is now removed and 
a little more blood allowed to drip 
back. To the irrigating jar is joined 
a sterile tube with a clip or cut-off and 
a glass connecting tube, larger at one 
end to fit it, and smaller at the other 
to fit that tube which fits the canula. 
The nurse releases the saline, and the 
doctor, not depending on her report 
of the temperature, though not deny- 
ing it, lets some run over his arm or 
hand, then, all noting the point at 
which it stands in the jar, the saline 
is injected into the vein by connecting 
all the apparatus. Irrigators must all 
be graduated. Some number at the 
top, much the better way. If order- 
ing mention this. If 50 c.c. were run 
off before the patient begins to receive 
any, and at 750 c.c. we stop because 
he shows sufficient reaction, he re- 
ceived only 750 — 50 c.c. or 700 c.c. It is 
also better to graduate in cubic centimeters, since the small 
amounts can be meticulously gauged. Some jars are 
built like a bottle with a spout at the bottom; others are 
a modified inverted cone, tapering to fit the lumen of an 
ordinary tube. These give general satisfaction, and it is 
useless to cover them at the top. They give a very steady 
flow on account of the generous surface, and the speed 
can be controlled below by slight pressure on the tube to 
prevent dilatation of the heart. The temptation always 



Fig. 42. — Infusion 
canula with stop- 
cock (Bellevue Hos- 
pital) . 



MINOR WORK IN THE OPERATING ROOM 237 




Fig. 43. — Potain's aspirator, 60 c.c. — metal barrel and metal 
piston, three needles, one stop-cock, one trocar, and tubing. 




Fig. 44. — Bottle for Potain's aspirator, 500 c.c. 



238 OPERATING ROOM 

is to hurry. That is a mistake. The only cause for hurry 
is the patient's bad condition or the cooling of the saline. 
The temperature of the solution is a mooted one. It is 
usually started at 120° F. to allow for slow delivery, 
cooling while in the long tube; but it must be delivered at 
98.6° to 100° F., practically at body heat, not cooler; 
therefore we need two thermometers, one to test the 
solution in the tank and one to test it just before it enters 
the vein. A bath thermometer, stripped of its wooden 
casing and kept in an antiseptic solution, then rinsed in 
sterile water and held by forceps, may be used above. 
An "infusion thermometer" consists of a large glass 
connecting tube with a thermometer placed stationary 
inside of it. It is of equal lumen at the ends, and we 
simply cut the long tube from the jar and slip it in near 
the lower end. It registers from 90° to 104° F., and it is 
imperative to have it in all hypodermoclysis, infusion, 
and Murphy drip sets. If the solution runs too cool, a 
small amount of hotter saline is cautiously added, watch- 
ing the upper thermometer; about 1 ounce at a time, 
since it goes slowly down the tube, but runs up the 
mercury fast when it gets there. Cool should be added 
similarly when the other is too hot. The tube should be 
pinched low down until these temperatures are adjusted. 
Hurry and excitement are sinful at such a time, and are 
not any excuse for administering too cold or too hot a 
solution. The amounts added must be kept in mind. 
If all is going well, and the patient will take more than the 
jar holds, a new amount of the right temperature is carried 
in a sterile, pitcher and poured in without touching the 
latter to the jar and covered with a sterile towel while 
carrying. When about to pour it in the long tube is 
pinched below the infusion thermometer, and the amount 
in the jar noted. Say it stands at 740 c.c. When we know 7 
more will be needed, it must be added before the old 
solution gets below the lowest mark — (a) so that we can 
estimate it; (b) so that no air will get into the vein. When 
filling any glass container for the first time cool liquids 



MINOR WORK IN THE OPERATING ROOM 239 

should be poured in first, then the hot is so tempered that 
it cannot break the glass. If then we fill it up to c.c., 
we have added 740 c.c. If it was standing at 750 c.c. 
when we stopped, and we filled it to 150 c.c, then we 
added only 750 — 150 c.c. = 600 c.c. to the original 
amount. 

The bottom of the irrigating jar should not be more than 
one foot above the patient's body, and everyone else con- 
cerned must be patient, too, while it runs evenly. The 
sterile tape boiled with the jar hangs it to the stand. 
The towels, iodin, and set should be brought first, so that 
by the time the incision is made the jar of saline is in 
position. The patient's pulse, respiration, color, finger- 
tips, skin, and other features must be closely scrutinized, 
and when they are all again normal the treatment is 
stopped. The proximal ligature has already one loose 
knot in it, which is now tightened over the canula, which 
is withdrawn, and the saline cut off, then the ligature is 
tightened, knotted, and the wound sponged out. A 
couple of sutures with a straight or curved Hagedorn 
needle close the wound with plain catgut. It is dusted 
with aristol, covered with folded gauze, and snugly ban- 
daged with gauze, not so as to interfere with the movement 
of the arm. Mouse-tooth forceps must not be used on the 
vein. The artery clamp of the set will stop any small 
bleeders. The probe may help in locating the vein. 

It is most expedient to make saline up in triple strength, 
that is, 3 drams to 1 pint, for this very purpose, so that 
the very hot may be diluted by twice the amount of cold 
sterile water. To make it triple strength saves space and 
time, but it must be marked so, and everyone must have 
that understanding also. Nurses from the wards rush- 
ing up for supplies should not help themselves. Saline 
is given out by a reliable member of the pupil staff. At 
night, when all supplies are locked away, only the night 
supervisor or some pupil who "has had operating-room" 
should have access to the stock, leaving a note on the 
spindle saying where it went and what its use. 



240 OPERATING ROOM 

Infusion Set. 

Irrigating jar with tubing and tape. 

Cut-off. 

Dairy thermometer. 

Infusion thermometer. 

Glass connecting tube. 

Canula (silver only). 

Fine rubber tubing (never cut a catheter). 

Scalpel with free curved edge. 

Thumb forceps. 

Mouse-tooth forceps. 

Artery clamp. 

Probe. 

Grooved director. 

Curved scissors. 

Hagedorn needle, curved or straight. 

Plain catgut No. 1. 

Infusion stand. 

Table for the arm. 

Sterile towels. 

Flat gauze and sponges. 

Bandage, 2-inch gauze. 

Tourniquet. 

Aristol. 

Saline flasks, asbestos mat. 

Hot and cold water (pitcher). 

Iodin, 2.5 per cent. (J tincture, f pure alcohol). 

Sponge pail. 

To Put Up the Infusion Set. — The set should be kept in 
readiness in sterile covers on a tray inside a locked cup- 
board. It should be opened at regular intervals to see 
that everything is in it and rustless, then resterilized. 
The very best of instruments should be used. Wash after 
using, scrub with Bon Ami, and boil the irrigator, three 
tubes, cut-off, canula, scissors, clamp, forceps, probe, 
grooved director, needles, glass connecting tube, but soak 
in bichlorid (1 : 1000) the catgut and two thermometers, 
and in carbolic acid and alcohol the scalpel. Lift the tray 



MINOR WORK IN THE OPERATING ROOM 241 

out of the boiler to drain the boiled articles, dry, and 
handle them with sterile forceps. On a clean table lay 
sterile towels as a cover. Above these lay sterile towels 
folded double laterally to be used to put up the articles. 
Keeping the hands under another sterile towel, and lifting 
each article by a forceps, wipe it thoroughly dry and lay 
it in its towel cover. Similarly do with the catgut knife 
and thermometers, rinsing them under the sterile water 
tap. In one package place the irrigator with its tape and 
cut-off, two pieces of large tubing, dairy and infusion 
thermometers, so that if need be it may be used to give a 
hypodermoclysis. For this purpose we do up separately 
after that treatment a glass Y, two fine pieces of tubing, 
and the hypodermoclysis needles (a pair with stylets), 
sterile or simply clean and ready for boiling, because they 
can be easily boiled in time. Each package should be 
fastened securely with buried pins and labelled with ad- 
hesive or gummed labels. The nurse who does them up 
should write her name on the outside of the package. 
Dry sterilization is not so dry that it is good for instru- 
ments. It rusts them. These bundles must always be 
kept in the same place. 

In the second package put the canula, scissors, clamp, 
mouse-tooth and thumb forceps, probe, grooved director, 
glass connecting tube, fine rubber tubing, scalpel, needles, 
and catgut, which may be used also for phlebotomy. 

Infusions must not go wrong. Hospitals have disgrace- 
ful traditions about infusion sets, aspirators, and cauter- 
ies, so that it has come about that the doctors are sur- 
prised if they go well. Any tiny hospital should have at 
the very least two infusion sets complete — (a) in case two 
patients need it at once; (b) in case parts of a set are lost 
or are being renickelled; (c) in case a patient requiring it 
is in isolation. A list of what belongs to any set should 
be found in the house-book of rules and pasted on the tray 
where the set is kept. 



16 



242 OPERATING ROOM 

II. HYPODERMOCLYSIS 

For all these treatments put the bedside table near the 
foot of the bed, but on the right-hand side. 
Required : 

(a) Two needles with stylets, all in good condition 
(dried over an alcohol flame, then lubricated, assorted 
sizes); 2 pieces of fine rubber tubing to fit them; 1 glass Y. 
(Kept together at. all times.) 

(b) One sponge-holder (from the ward) for iodin. 

(c) Jar or irrigator for saline with tape loop; long rub- 
ber tube containing infusion thermometer; cut-off; dairy 
thermometer. (Kept in one set as for infusion.) 

(d) Stand, collodion, iodin in 2-ounce glass, towels, 
cotton, pus basin, sponge pail (on floor), sponges. 

The saline is prepared as for infusion. If triple strength, 
it is diluted with hot and cold sterile water. The hot 
flasks, if normal, must not be set on a glass table without a 
thick covering, to prevent cracking the table. 

Set the table with sterile towels lifted out of their cover 
by the ward forceps (in lysol). Lift the boiled articles of 
(a) out of their basin at the bedside and lay on the towels. 
Lift out the thermometer, sponges, cotton, etc., and 
hang up the jar, holding the end of the tube with forceps 
on the table so that it will not become unsterile. Place 
the iodin at one edge so that it will not be in the way after 
the start is made or contaminate the rest. Place the 
sponge pail and pus basin so as to catch the overflow 
while the needles may be adjusted. When pouring into 
the irrigator do not touch the two containers together. 
Pour a little cold solution first always, so as to prevent the 
hot from cracking the glass. While the doctor, who has 
scrubbed up, is fitting the needles, withdrawing the 
stylets that are always to be boiled in them, adjusting the 
glass Y and the tubing,, the nurse prepares the patient. 
The arms are placed above the head, the gown drawn up 
to the chin and tucked tightly under the shoulders, the 
face shaded by a tow T el if conscious, and sterile towels laid 
across the chest and abdomen above and below the nipples 



MINOR WORK IN THE OPERATING ROOM 243 

(breasts). The doctor applies iodin to both surfaces of 
injection (the base of the breasts) with sponge on holder. 
The nurse operates the cut-off so that the solution runs 
until the temperature below is 100° to 102° F., then the 
cut-off is tightened and the needles inserted while stand- 
ing full. Then the cut-off is opened, and the doctor gently 
massages the solution back into the farther tissues and 
watches the temperature, the patient's appearance, etc. 
The nurse notes the amounts, as in infusion, replenishes 
it when it runs low, and tests the temperature above, also 
taking the patient's pulse from time to time. One wound 
is dressed with collodion on cotton before withdrawing the 
second needle, so that none runs out due to internal pres- 
sure. Usually the amount is 1000 to 1500 c.c. That 
can be very well borne. The patient is then made com- 
fortable and all things cleared away. 

These articles must be immediately washed, boiled, 
and sent to the operating room for final sterilization. 
Even when that process is only boiling, putting up these 
packages must be done by an operating-room nurse, and 
she must see that the ward returned everything O. K. 

Irrigating jars look very clean if dry sterilized, but, on 
the other hand, that rots their tubing. If boiled in a 
towel no scum should adhere. 

Use small needles for children. 

INJECTION OF BLOOD-SERUM 

In certain conditions of (1) hemorrhages of the new- 
born, (2) traumatic hemorrhages, (3) hemorrhages after 
operations, and (4) purpura hemorrhagica (early) the 
loss to the general circulation is sometimes restored by the 
injection of blood-serum. As in transfusion, the blood 
of a very near relative by consanguinity — that is, one's 
own parent or a descendant of the same parents as one's 
self — must be obtained. For a newborn infant the father, 
and for a newly delivered woman her father, mother, 
brother, or sister. The blood from the donor is with- 
drawn, set in the ice-box in a sterile open-mouthed vessel, 



244 OPERATING ROOM 

but covered, to permit taking out the clots easily after 
they form, yet let nothing unclean drop in. In twenty- 
four hours, when the coagulable matter has collected into 
one clot, the serum, now absolutely clear and slightly 
heated to body temperature by standing in tepid water, 
is injected by a large ground-glass syringe in doses of 
15 to 25 c.c. in the patient's buttocks. As a rule, the 
second treatment is the last. In all these cases the donor 
shows marked effects : (a) Bluish patches under the eyes, 
which are sunken; (6) general lassitude; (c) great disturb- 
ance of the heat centers, heat sensations rapidly and 
irregularly alternating with cold, showing that he must be 
put to bed until his circulation is readjusted. The injec- 
tion is performed with strict asepsis. 

TRANSFUSION 

Transfusion means transferring blood directly and 
while yet warm from the body of a healthy donor to the 
body of a patient. It must be distinguished from infusion 
in these ways: 

(a) In infusion the fluid is saline. 

(b) In infusion there is only one person treated. 

(c) In infusion there are no tests for coagulation, etc., 
required. It is indicated, according to the best authors, 
in the following cases : gastric and duodenal ulcer, typhoid, 
ectopic pregnancy, tonsillectomy followed by hemorrhage, 
purpura hemorrhagica (advanced), hemophilia, carbon 
monoxid poisoning. 

The blood must be tested by a skilled pathologist to de- 
termine the degree of agglutination, which should corre- 
spond in the donor and the patient. The donor should 
preferabty be a blood relation, that is, the father, mother, 
uncle, sister, brother, son, or daughter of the patient. If 
the blood of a cat were injected into a human being the 
latter would possibly die after the first and positively after 
the second injection. Vice versa, if a man's blood were 
injected into a cat, the latter would die of blood destruc- 
tion or hemolysis. 



MINOR WORK IN THE OPERATING ROOM 245 

The strictest asepsis is required. The two persons lie 
parallel on two operating-tables of equal height. The right 
arm of the patient and the left arm of the donor, or vice 
versa, are cleansed and then wrapped in sterile towels, laid 
on a table of the same height, midway between. At the 
foot stands a similar table for the "scrubbed nurse," who, 
during the operation, constantly washes the syringes in 
water at about 100° F. If upon careful inspection it is 
found impossible to use the median basilic vein, a more 
extended search is made for suitable vessels, which will 
necessitate a different placing of the persons. 

The operator punctures the patient's arm with the 
common salvarsan needle, lubricated inside with sterile 
liquid albolene, then the donor's arm with a second. 
The venous blood ascends the arm and the needle taps an 
ascending stream, but the blood, flowing back, bleeds only 
a little, and it is merely sufficient to fill the needle and ex- 
pel all air before the syringe is fitted on. 

On the arm of the donor the first syringe is filled. 
These are 20 c.c. in content, of ground glass, the best to 
be had, working beautifully. About six syringes should 
be kept constantly on the go to expedite the process. 
Being reasonably healthy and at least mildly excited, the 
donor has an increased blood-pressure which may fill the 
syringe by pushing back the piston without aspiration. 

The operator lays down the full syringe, swiftly raises 
another, and lets it fill. The moment he relinquishes one 
full syringe the assistant fits it to the needle in the pa- 
tient's arm, injecting all but about \ dram, which he ex- 
pels to show that he did not drive air into the vein. A 
nurse keeps count of the number of syringes filled. The 
operation never ceases until enough is injected to meet 
the demands — 1 pint, or twenty-five 20-c.c. syringes, can 
be injected in nine minutes. 

Another assistant is . required to pass the syringes to 
and from the nurse continuously. 

The needles are withdrawn and the slight wounds 
dressed with cotton and collodion. There are no incisions, 



246 OPERATING ROOM 

no scalpels, no great chances for infection. The patient's 
color, lips, nails, pulse, and respiration should be very 
closely watched during this delicate but 'brilliantly showy 
performance. 

PHLEBOTOMY, VENESECTION, BLOOD-LETTING 

The doctor used to be called "the leech" at a time 
when all disease was supposed to be due to having too 
much blood, and living leeches sucked out the overplus. 
Later the physician used a scalpel and saw how much he 
"let." But phlebotomy is now rather rare, and only in 
conjunction with an accurate diagnosis made by the assist- 
ance of a sphygmomanometer. In the "open" method a 
wound is made and the vessel then tied off twice, as in 
intravenous infusion. Required: 

(1) The instruments of the infusion set, scalpel, forceps, 
catgut, etc. 

(2) Pus basin to catch the flow of blood, graduate to 
determine the amount, and pail. 

(3) Large rubber to protect the bed, sterile towels, 
sponges, etc. 

Set the table as for infusion. Do not let the patient- 
see the red stains and cause him needless alarm. Watch 
the force of his pulse-beat. Do not allow any blood- 
stream to escape unnoticed and uncalculated, thereby de- 
pleting the patient too greatly. 

In the "closed" method, to. obtain only a very small 
amount, as for blood cultures, which must be conducted 
in an aseptic manner, a needle is employed to puncture 
the vein, but there is a special technic arranged by pathol- 
ogists for cleansing the skin, disinfecting instruments and 
containers, etc., which should be posted in each hospital 
and arranged for by the ward nurses to suit his conve- 
nience. His desire for asepsis is to prevent any outside 
germs from entering the blood, lest he attribute them to the 
patient himself. Our desire for asepsis is to prevent any 
bacteria from getting into the patient. 



MINOR WORK IN THE OPERATING ROOM 247 

LUMBAR PUNCTURE 

This is employed as a test for cerebrospinal and tuber- 
cular meningitis, and must be conducted with most aseptic 
precautions for two reasons: (a) Not to infect the patient; 
(6) to see his spinal fluid as it really is. 

Required : 

(1) Iodin, cotton, collodion, sterile 2-ounce glass, 
forceps. 

(2) Lumbar puncture needles, assorted sizes, special 
design, with bevelled stylet and an eye ^ inch above the 
point. 

(3) Sterile glass graduate to contain the first flow of 
fluid (small). 

(4) Sterile glass graduate to send whole amount to the 
laboratory, if necessary, and to estimate it, this fluid 
being sought by the big laboratories to manufacture 
from it antimeningitic serum. 

(5) Rubber sheet, towels, pus basin, sponges, etc. 
The patient's knees and chin are brought together so 

as to bow out the lumbar vertebrae. The area is painted 
with iodin, then, the landmarks being carefully taken, 
the needle is inserted, the smallest glass held beneath it, 
and the stylet withdrawn. Ethyl chlorid destroys the 
landmarks by freezing. 

To inject antimeningitic serum, required: 

(1) The serum, standing in a tepid solution of bichloricl 
of mercury, 1 : 3000, at a temperature of 100° F. It must 
be allowed to run in at body temperature in such a vital 
spot. 

(2) Special glass and tube, as for spinal anesthesia. 
This glass is like the outside of a large glass syringe, open 
at both ends, the lower tapering and the whole graduated. 
It contains 20 c.c. and fits a fine piece of rubber tubing 
which, in turn, fits the needle. No air is allowed to enter 
and no force is employed. The cord is not aspirated, 
just tapped — i. e., the fluid is let run out by gravity. 
Similarly it is let run in by gravity, never propelled by a 



248 OPERATING ROOM 

piston. If the serum were used cold it would cause a 
subnormal temperature and additional discomfort to the 
patient. 

SPINAL ANESTHESIA 

Spinal anesthesia is an exact duplicate of the above, 
except that the fluid introduced (without any force) is a 
chemical substance, innocuous to heart and kidneys in 
the normal individual, while chloroform is injurious to 
the one and ether to the other. 

In addition to the articles above named is found a small 
sterile glass, into which the ampoules of stovain are first 
broken and whence it is poured into the special graduated 
tube for introduction into the cord. 

The patient is stripped to the waist of his loose operat- 
ing-room garb, and sits on the operating-table in the main 
room, leaning forward with his arms over the shoulders 
of a shorter person standing close to him so as to bow out 
his back at the lumbar region. The area is cleansed with 
iodin and alcohol, then the spinal fluid is drawn off. It 
is not required for examination or measurement. The 
tube for stovain is connected and held very low, to show 
the presence of spinal fluid, to which the stovain is now 
added, so as not to introduce any air, then raised to a 
normal position. The patient's arms are drawn above 
the head and the eyes covered. Then his sensation is 
tested, from the toes up to the point selected for the 
wound. When complete anesthesia up to the desired 
point is obtained, he is laid on the table and the opera- 
tion begun. Some patients have died following this 
anesthetic and others have died from the effects of the 
operation, while it has for still others been ideal. 

ARTIFICIAL RESPIRATION 

This is positively the duty of the physician, but in case 
he is not to be found, or has been incapacitated in any way, 
a nurse should know how to perform it, just as it is done 
by the Life Saving Corps or by gymnasium instructors. 



MINOR WORK IN THE OPERATING ROOM 249 

The Sylvester method is very satisfactory because it 
can be comprehended by others than physicians. 
General Rules: 

I. Never give up hope; keep up the treatment for at 
least ninety minutes. 

II. Consider the patient alive at the start. 

III. Carry out the treatment where the patient is. 

IV. See that there is no obstruction in the nose or 
throat. 

V. Do not get excited and do not give too rapidly. 

VI. Elevate the patient's shoulders about 4 inches. 

VII. Clamp the tongue, and let another assistant 
draw it forward with each expiration, and not let it drop 
back, ever so slightly, with each inspiration, impeding it. 

VIII. Stand or kneel far enough above the patient to 
have good purchase when pressing downward behind 
his head. 

IX. Make the (inward and outward) respirations for 
an adult 16 to the minute — that is, 3f seconds each — 
two seconds for the inspiration and almost two seconds for 
the expiration. 

X. (a) Grasp him by the forearms, half-way between 
elbows and wrists, and draw up his arms out and over his 
head steadily until the hands touch the table, floor, or 
ground behind his head. Hold them there for two sec- 
onds. This motion expands the chest by drawing up the 
ribs; air may enter. Two seconds' halt allows it plenty 
of time to fill the lungs completely, (b) Reverse that 
movement. Carry the arms downward until they rest 
against the sides of the chest, bringing the forearms in a 
little on top, pressing them firmly downward and inward 
against the chest for one second. Listen for the sound of 
air entering and leaving. If not heard, the work has been 
done incorrectly. 



CHAPTER XIX 

PREPARATIONS BY THE NURSE IN 
ORTHOPEDIC SURGERY 

Open work on bones requires the most assiduous 
efforts at asepsis, but this has been discussed briefly 
elsewhere. Closed operations, or the breaking, straight- 
ening, and overcorrection of bone, show no open wound. 
But poor or improperly prepared materials hamper the 
orthopedic surgeon very greatly, much more than the 
dressings for a laparotomy could do, if clumsy or un- 
familiar. Plaster work requires in a surgeon a natural 
aptitude or knack, but the most wonderful knack cannot 
make a good cast out of poor crinoline, inferior plaster, or 
badly soaked bandages. Making plaster bandages is a 
regular part of the operating-room training, and must not 
be relegated to an orderly. 

Definitions. — Surgical Diagnosis. — For deformities cer- 
tain technical terms are used: 

Congenital dislocation of the hip. A deformity existing 
from birth, the head of the femur being lodged outside the 
acetabulum, with the formation of powerful adhesions. 
Frequently this occurs in both sides. • 

Funnel breast. A depression of the chest walls at the 
sternum resembling the bowl of a funnel. It is like a 
shoemaker's chest, only it may occur at any point. It 
is corrected by very strenuous exercises, not by operation, 
but must be done early to abort any hereditary predis- 
position to tuberculosis by increasing the child's lung 
capacity. 

Genu valgum. Inward curving of the knee, knock- 
knee, opposite of bow-legs. 

Genu varum. Splay foot; synonym of talipes valgus^ 
bow-legged; inner part of the sole rests on the ground. 

250 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 251 

The preceding are neuter nouns and adjectives, there- 
fore the latter end in um. 

Hallux valgus. Displacement of the great toe toward 
the other toes. 

Hallux varus. Disposal of the great toe away from the 
other toes — displacement. 

These are masculine, therefore ending in us. 

Hip disease. Usually tuberculous and in the young. 
It lodges in the head of the femur, in the acetabulum, or 
in the synovial membrane and proper structures of the 
hip-joint. The early symptoms are shuffling gait, pain 




Fig. 45. — Osteoclast (Phelps' modification of Grattan's). 



on the inner side of the knee, pain in the hip on jarring the 
heel, deformity, shortening of the limb, suppuration, and 
formation of flstulse. 

Kyphosis. ■ Angular curvature of the spine, the promi- 
nence extending posteriorly. 

Lordosis. Curvature such that the convexity points 
forward. 

Osteoclast. Instrument to break bones to correct de- 
formity (Fig. 45). Do not confuse with the term "osteo- 
blast," which means a cell found in the formation of bony 
tissue in the embryo. 



252 . OPERATING ROOM 

Pott's disease. Curvature of the spine with a poste- 
rior projection due to spondylitis or inflammation of a 
vertebra. It is usually tuberculous. It may be high 
or low. When high, it is more quickly discoverable; 
when low, it shows up usually as a psoas abscess, the in- 
flamed area breaking down into pus which migrates down- 
ward along certain muscles toward the inguinal region. 
The symptoms of Potts' disease are stiffness of the spinal 
column, pain on motion, tenderness on pressure, undue 
prominence of one or more spines, and a particularly 
wistful facial expression. 

Scoliosis. Lateral curvature of the spine, bending of 
the column to right or left. 

Talipes. Club-foot. 

Talipes equinus. The heel is elevated, and the weight 
is all thrown on the anterior portion of the foot, like a 
horse's foot. 

Talipes planus. Flat-foot. 

Talipes valgus. Foot turned outward. 

Talipes varus. Foot turned inward. 

APPARATUS 

A Bradford frame may have to be constructed quickly 
to provide horizontal fixation in cases of children suffering 
from fractures or from tuberculosis of the spine. The 
frame itself is of bent gas-piping, from f to \ inch thick, in 
a perfect oblong, 1 inch wider than the patient's body at 
his hips, and 6 inches longer than his full stature; that is, 
in the proportion of about 1 to 5. It is covered by a 
piece of stout canvas twice its width, and laced down the 
back on the center of the side away from the child with 
eyelets and stout laces. It is arranged to leave an open- 
ing for the bed-pan, which, however, does not interfere 
with the tautness longitudinally, which is taken care of 
by two pairs of webbing straps at the head, and again 
at the foot. This frame is constructed to obliterate pain, 
and the child can be very comfortably carried on it. In 
spinal cases he may lie and kick all he pleases if his feet 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 253 

are warmly clad. As to bodily clothing, otherwise, when 
he is applied to the frame, he wears only undershirt and 
diaper. His warm dress is put on, last of all, over the 
jacket of the frame. Two thick pads of felt are sewed 
on the canvas, each 7 inches long and f inch thick, to 
protect the hump from pressure and to increase the 
leverage of the apparatus. Mangle felt is excellent for 
orthopedic purposes. There should be a small square of 
rubber covered with muslin at the region of the buttocks. 
To make the frame more effectual, it may be bandaged 
with strong muslin bandages, with edges turned in, be- 
fore applying the laced canvas top. This frame is 
gradually bent, under the kyphosis, to curve upward 
from the bed to the hump, the ends resting on the bed. 
This obliterates the hump in time. Much orthopedic 
work with braces, frames, and suspension apparatus is 
really a daily "operation" by the nurse. The child is 
taken off the frame daily, handled painlessly, bathed, 
rubbed with alcohol, and powdered. It is essential to 
have two canvas covers for each frame. To secure the 
patient to the frame an apron of canvas, covering the 
child's chest from the armpits to the hips, is provided, 
with three pairs of straps of webbing and buckles, fasten- 
ing in the back on the under side, immobilizing his body. 
The fixation must occur in the region of the disease — i. e., 
for lumbar disease a broad binder should be passed over 
the hips, and if there is psoas spasm, traction is usually 
employed. 

Buck's extension (Fig. 46) consists of the following parts, 
all of which should be kept together in a set in a chest : 

(1) Two strips of moleskin plaster, each 2 or 3 inches 
wide and extending from the seat of the fracture to the 
internal malleolus. 

(2) An alcohol flame to melt the adhesive. 

(3) Two pieces of webbing for each leg, to be stitched 
to the plasters at their ankle end, 2 or 3 inches wide and 
6 inches long. 

(4) Five other strips of moleskin, each 1^ inches wide, 



254 OPERATING ROOM 

to encircle the leg, the knee, and the thigh, also to extend 
spirally from the malleoli around the leg and thigh to the 
seat of fracture. 

(5) Roller bandage of 3-inch muslin, with the edges 
turned in during application, then stitched in neat rows, 
to be kept in place. 

(6) A curved or straight ham, or posterior, splint prop- 
erly padded. 






Fig, 46, — Apparatus for Buck's extension, with rope and weights. 

(7) Three coaptation splints to surround the thigh. 

(8) Six webbing straps with buckles or strips of band- 
age to be used as straps. 

(9) Fresh sheets, pillowslips, or towels as pads. 

(10) A straight abdominal binder for the pelvis. 

(11) A long axillary or outside splint of wood, 4 inches 
wide, from the axilla extending 6 inches below the sole 
of the foot. 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 255 

(12) To this is nailed a cross-piece 18 inches long, 
making a T. 

(13) Two towels, soft and old, or 2| yards of flannelette 
(one-fourth the width) for a perineal strap. 

(14) Safety-pins arranged with their points in a cake of 
Castile soap. 

(15) A pulley, screwed into a broom-handle cut the 
right height or attached to a special iron bar (part of the 
set) that clamps in two places to the bed frame. 

(16) A spreader, being a piece of wood 2 inches wide 
and a little longer than the width of the patient's foot, 
with a hole bored in the center for the cord, on which hang 
the weights for extension. 

(17) A piece of clothes-line (cotton rope) 4 or 5 feet 
long. 

(18) Two shock blocks to elevate the foot of the bed. 

(19) Four sanci-bags with white muslin slips, each 
20 inches long and 6 inches wide. 

(20) A square cradle, made of pine, fir, or cedar, to keep 
the weight off the limb. 

(21) A soft, warm old blanket for the limb, lying closely 
over it. 

(22) Cotton covered with gauze to stuff into corners 
(this prevents fluff from spreading through the bed). 

(23) A fracture-board or a plain level old door, with 
holes bored through it to air the mattress on the under 
side. 

(24). Needle, thread, thimble. 

(25) Tape-measure. 

(26) Weights, graduated and recorded as to amount, 
when used. 

(27) Anesthesia set, vaselin, pus basin, towels, etc. 

(28) A railroad (old-fashioned, but still in vogue) — a 
track of wood on which the leg glides smoothly. 

Such a list as this, combining with the basic articles 
here enumerated any favorite materials of the operator, 
should be posted in the treatment room where this sort 
of work is done. 



256 OPERATING ROOM 

The Lorenz operation for congenital dislocation of the 
hip, consisting of bloodless reduction, retention, weight 
bearing. 

For bloodless reduction no instruments are required 
but the surgeon's hands; a thick folded sheet beneath the 
patient's buttocks; a wedge of wood (for all but tiny 
children) about 5 inches long, 3 inches wide, and suitably 
padded to form a fulcrum under the head of the femur; 
a second sheet folded diagonally to make traction from 
the perineum, with the ends tied about a corner of the 
table. 

If the reduction requires two sittings, a plaster spica is 
required for the first, and certainly after the last. The 
following special articles are to be provided: 

(1) A close-fitting long stockinet shirt, one-half of 
which is cut and sewed to cover the limb as a drawer leg 
would do. 

(2) This drawer is "threaded" with a long bandage, 
called the scratcher, which runs down as a loop inside the 
drawer and up outside the cast, to give the patient or 
nurse a means of rubbing the skin underneath when it 
itches. 

(3) The hip or pelvic rest to elevate the body for all 
spica work. 

(4) Sheet-wadding, with glazed surface preferably, or 
cotton in long rolled strips, 4 inches wide, to cover the 
pelvis and thigh thickly. 

(5) A firm bandage of muslin for elasticity and com- 
pression (may be preceded by a fine smooth gauze 
bandage) . 

(6) The plaster spica, very thick and firm, consisting 
of a dozen or more ordinary plaster bandages, embracing 
the iliac crests, the buttocks, and the leg to, but not over, 
the knee-joint. 

(7) Plaster scissors to cut away the edges; then they 
are everted. 

(8) Stout thread with needle to sew the stockinet (when 
it is smoothly turned up over the edges) to itself. 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 257 

(9) The stimulation tray with the anesthesia set, be- 
cause many deaths occur from the violence of the rupture 
of these congenital adhesions under the anesthetic. 

(10) A cork sole of 1| to 3 inches in thickness should 
be early ordered for the affected foot when walking begins 
in the third week. 

Ordinary Plaster Bandages. — In hospitals where ortho- 
pedic surgery does not constitute a special branch of work 
there are at least many occasions when plaster casts must 
be applied. To make the bandages are required: 

(1) A large flat tray. 

(2) The best of crinoline, of a standard fineness and 
thickness, this being the foundation of the whole system. 

(3) Excellent dental plaster of Paris. 

(4) A spatula to apply the plaster to the crinoline, 
though most nurses prefer to go ahead with the bare 
hands. 

(5) A tape-measure and stout scissors to measure, cut, 
and roll the crinoline in 5-yard lengths of the usual widths 
— 3, 4, 5, and 6 inches. 

(6) Small round tin boxes, one for each bandage, lidded, 
or squares of blue tissue such as comes with cotton, to 
roll up each bandage separately, then laying them on their 
side in a large square tin box with lid, to be kept per- 
fectly dry. 

(7) A rubber apron and, if the skin is abraded or 
suffers from contact with irritating clays, thick rubber 
gloves. 

(8) A solid stool and table with foot-rest. 

The bandage must have all the plaster it can hold, and 
this must be evenly distributed throughout its whole 
length. It is set on the left-hand side, unrolled, filled 
with plaster, much lying under it on the tray, smoothed, 
and rolled up to keep it ship-shape on the right as one 
goes along. It must be rolled only about 75 per cent, 
tight — that is, fairly loose — so that water may circulate 
between the layers of plaster later. It is of vital moment 
to keep up the stock of plaster bandages. If on any one 

17 



258 



OPERATING KOOM 



day they run too low, they should be replenished that same 

day before the nurses go off duty. 

For putting on a cast the following articles are required : 
(1) Gown, rubber apron, and unsterile rubber gloves 

for the surgeon (also rubbers with high tops to cover his 

shoes, if he chooses). 




Fig. 47. — Curved plaster-of -Paris knife. 

(2) Newspapers, rubber sheets, etc., to cover the floor. 

(3) Ammonia, alcohol, or vinegar to soften the old 
cast or cleanse the hands. 

(4) Special knife, saw, and shears for cutting casts 
(Figs. 47, 48, 49). 




Fig. 48. — Saw for plaster-of-Paris cast. 



(5) Stockinet, shirt, drawers, or stockings of cotton or 
Balbriggan to protect the body (the pupils should save all 
their cast-off white hose for this purpose, especially for 
arm cases); bandages of stockinet are good for any por- 
tions of the body not ordinarily clothed with knitted 
goods, 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 259 

(6) Mangle felt in strips or squares, to pad or give 
elasticity with compression. 

(7) Sheet-wadding, glazed, preferable to cotton, in 
many rolled strips, 4 inches by 1 yard. 

(8) Cotton, alcohol, and powder to rub and pad all 
humps or edges, even after everting the stockinet cuffs. 




Fig. 49. — Plaster-of -Paris shears. 

(9) Oiled silk, to form, at the edges near the genitals 
a surface impervious to urine or stool. 

(10) Hip rest of metal or wood (also convenient for the 
spica in hernia) if no orthopedic table is to be had. 

(11) A large enamel basin, 8 inches deep, in which to 
set the bandages on end, with plenty of space for the 
water to submerge them plus the nurse's hands, without 
overflow. 



260 OPERATING ROOM 

(12) Water at the temperature of 100° F., kept so by 
adding hotter from time to time from a pitcher nearby; 
a bath thermometer. 

(13) A solid table protected with rubber sheeting and 
an old cotton blanket. 

(14) Old soft blankets on the patient; warm-water 
bottles, each with two covers not warmer than 110° F.; 
a burn through a cast, not being easily discovered, is apt 
to be very deep and lasting. 

Special Instructions to the Nurse. — (1) Set the ban- 
dages on end, only one at a time, and hold them so with 
both hands until they are wet through. Bubbles begin 
to rise continuously in their center, and when these bubbles 
cease they are wet enough. 

(2) Squeeze the bandage until one-half the water 
oozes out, then hand it to the surgeon so that he may 
take the bulk of the roll in his right hand and the free 
end in his left. The distance from the nurse's basin to 
the surgeon's hand should be the shortest possible. 

(3) Just as soon as the nurse relinquishes one bandage, 
she removes the wrapper and steeps a second, that time 
corresponding to the length of time required by an ex- 
pert orthopedic surgeon to apply one. 

(4) When all are on, she should, with both hands, 
scoop up the sediment left after pouring off the bulk of 
the water and pass it to the surgeon or keep it soft and 
equally mixed while he makes with it an extra coat quite 
smooth over all. 

(5) At times it is necessary to bolster the cast by first 
applying a plaster splint which is best made on the oper- 
ating-table. Therefore a space must be cleared by flex- 
ing the patient's other knee, or on the work-table used by 
the nurse, a glass or rubber surface being preferable. 
The measure is taken on the limb, then a wetted bandage 
is laid flatly on the table and folded on itself longitu- 
dinally. If this w T ere a 5-inch bandage it would make 
five thicknesses 1 yard long and 5 inches wide, which 
would probably be thick enough. These splints are al- 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 261 








Fig. 50. — Fracture and orthopedic table in position for treating 
fracture of the lower extremity — adaptable to rontgenographic 
examination. 




Fig. 51. — Fracture and orthopedic table, illustrating control of the 
leg in bone-plating for fractures. 



262 OPERATING ROOM 

ways made the single width of the bandage provided. 
Their length depends on the bone being set. 

(6) When a cast has been put on, the old cast is broken 
up into small fragments to fit the trash-cans easily, and 
to avoid scaring some one who comes across a ghostly 
"limb" in the dark basements. 

Most important of all, the plaster must not be poured into 
the sink or hopper, since it sets and stops up the plumbing. 
The basins should be scooped out into papers, thickly 
wrapped about, and put into the trash-cans. 

Orthopedic Tables. — It is most unusual to find a stand- 
ard orthopedic table outside the special hospital, but it is 
an excellent though very expensive article, consisting of a 
series of contrivances for procuring leverage, elevation, 
gaps to pass bandages, extension, etc. (Figs. 50, 51). 

Adhesive Plaster Strapping for Flat-foot. — Adhesive 
plaster, 15 inches long and 3 inches wide, beginning at 
the outer side of the ankle, just below the external malle- 
olus. Adduction of the foot (drawing it up inwardly to 
form an artificial arch) . Passing the plaster tightly under 
the sole, up the inner side of the arch and leg. Two small 
strips of plaster, 1 inch wide, crossing it at the top, to keep 
it in place, but not completely encircling the leg lest they 
cut off the circulation. Measure with a tape before 
cutting. Then cut a series of six strips of adhesive, 
15 inches long and f inch wide, and cover this same 
area again, laying the back edge of each over the front 
edge of the one preceding, and catching them alternately 
in a braided or basket pattern, coming down from the 
top, with small strips running horizontally, working down 
to the malleoli, but leaving an open path down the in- 
step, 1^ inches wide, which may be bordered with two 
strips of the proper length to cover the raw edges. Over 
all apply a firm bandage. This should be removed once 
a week with ether or benzine, the foot examined and 
cleansed, then dressed again. 

Other orthopedic work than what has been mentioned 
would not be undertaken outside a special hospital. 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 203 

Orthopedic literature can be had in great quantities, its 
appliances are numerous, and long practical experience is 
absolutely necessary for a nurse to handle the little 
sufferers without inflicting needless pain. Below is given 
a list of terms that may be used in conversations regarding 
orthopedic cases which are too difficult for the general 
hospital to handle, but about which a nurse has a reason- 
able curiosity. Orthopedic cases are very long, and a 
nurse undertaking the care of one without previous 
training should at once betake herself to some institu- 
tion to get the "first principles, 7 ' since her patient is not 
an "emergency." Few women are blessed with a talent 
for mechanics, mathematics, or physics, and in ortho- 
pedic nursing all the skill depends on a knowledge of 
leverage, weights, pressure, and extension, added to pa- 
tience, sympathy, and gentleness of touch. Then, 
again, the special hospital has a staff of skilled black- 
smiths, carpenters, harness-makers, and shoemakers who 
work in conjunction to make a fitted support, consisting 
of a shoe and a brace for the leg, a jacket for the body, 
or a piece of apparatus with collar and pulleys for self- 
suspension, on patterns taken by the surgeons. 

SOME SPECIAL APPARATUS 

Jury Mast. — A frame of tempered steel, leather straps, 
and canvas to straighten and lengthen a curved spine, 
including as points of support the brow and chin and a 
point in the plaster jacket well below the deformity. 
Each must be accurately fitted to the individual and 
altered to suit his development. The hump must be 
well padded. Even with the most careful intentions 
frightful pressure-sores are caused by inexpert handling. 

Fracture-box. — A support for the leg when the tibia or 
fibula is broken (Fig. 52). 

Sayre's Suspension Apparatus. — A tripod, joined flex- 
ibly at the top and securely fastened when in operation 
by spikes into the floor. From the center at the top on a 



264 



OPERATING ROOM 




Fig. 52. — Fracture-box. 




Fig. 53. — Sayre's suspension apparatus for application of plaster 
jacket, or exercises. 



PREPARATIONS BY NURSE IN ORTHOPEDIC SURGERY 265 

pulley runs a halter, adjustable to a collar, that thus sup- 
ports the patient by the neck and chin. It is fitted to 
him, and he is then slowly raised until his toes are just off 
the floor. Then over only a knitted undershirt, with the 
proper pads and "scratcher," a plaster jacket is applied 
(Fig. 53). 

Modified Buck's Extension for Hip Disease. — There is 
no splint as for fracture, merely the weights. The patient 
is secured around the waist by a folded towel from which 
a bandage runs up to the head of the bed. With large 
children a perineal strap may be used. In any case, the 
foot of the bed may be elevated. 

NOTES 

The most modern bone operation is that of transplanta- 
tion. For Pott's disease, ununited fracture, etc., a very 
small piece is excised from the tibia and dovetailed into a 
crevice hewn out of the affected area. The hole in the 
tibia is replaced by healthy granulating bone tissue, not 
callus. Callus occurs in fractures. Small pins of tibia 
bone are inserted in holes drilled in the graft to maintain 
it in situ , just as a clever carpenter secures the pieces of a 
chair with wooden pegs. 



CHAPTER XX 

IMPROVISED OPERATING ROOM IN A HUMBLE 

HOME 

HINTS 

(1) Cold sterile water, boiled in clean kettles the night 
before for a morning operation. Have enough kettles. 

(2) Hot sterile water, boiled similarly a short time be- 
fore the surgeon's arrival. 

(3) Clean towels, old pieces of muslin of the size of a 
towel, put up in packages the day before, and sterilized 
as follows : Tie a cloth from handle to handle of a clothes- 
boiler to make a flat hammock above 2 gallons of water, 
and on that lay the packages. Lay the lid in position, 
and to its handle tie a heavy smoothing-iron to hold it 
down ("steam under pressure" or confined). Turn on 
the gas and boil for one hour. Remove the iron gently, 
then the lid very gently, so as not to permit the drops to 
fall on the packages. Lay them in a clean dry place to 
become perfectly dry, or dry them in the oven. 

(4) Laparotomy sheet, table -covers, etc., may be made 
out of sheets, pillowslips, etc. Do not destroy a good 
sheet for a laparotomy. Rather pin in position four 
pillowslips, fold, and sterilize. 

(5) The surgeon brings his own supplies — cap, gown, 
mask, gloves, instruments, catgut, etc. 

(6) Nowadays there is no reason why he could not 
bring his own dressings, but if he could not the nurse 
would make and sterilize a sufficient amount the day 
before. 

(7) Saline made within the same day it is used requires 
only one sterilization. Two 1-quart bottles are sufficient. 
The saline is made and boiled, if possible, the day before, 

266 



IMPROVISED OPERATING ROOM IN A HUMBLE HOME 207 

filtered, and poured into two boiled bottles, which are 
then plugged with gauze and cotton and sterilized with 
the dressings. By being made triple strength and 
diluted twice with cold water, they can be cooled for use 
if sterilized again the day of the operation (set in a con- 
tainer of water and brought to a boil, then kept at boil- 
ing-point one hour). 

(8) Vaselin, as a sterile lubricant, is set in its con- 
tainer (lid separate) in cold water, not quite to the 
edge, then brought to a boil and kept boiling for- one 
hour. After cooling in the container (burned fingers 
being res non gratce at this time) it is aseptically lidded 
and set aside. A small amount is taken out on a sterile 
grooved director when needed. 

(9) Basins for the hands, during 'the case will be found, 
from the gray enamel to the white stone china, in an 
old-fashioned bedroom.. If enamel or china, they are 
disinfected by standing in bichlorid of mercury solution 
1 : 1000 (preceded by vigorous scrubbing and rinsing). 

(10) For an irrigator (seldom used) a boiled douche- 
bag or can, covered with a towel and hung on a weighted 
hat-tree with smoothing-iron or brick tied to the feet so 
that it will not topple, may be used. 

(11) For a sponge and instrument table an ironing-board 
passed through the first and third panels of a clothes- 
horse, and all covered with sterile sheets, makes a safe 
place, easily set up and put away. 

(12) For operating-table, an extension table is good, 
fully extended and the middle leaves taken out and laid 
longitudinally, well padded for the patient's comfort. 
The width at both ends makes little tables for the operator 
and anesthetist. The surgeon and his assistant stand in 
the "waist." Or two small tables, tightly and solidly 
fastened together, padded with blankets, sheets, etc. 

(13) For improvised Trendelenburg, w T hich is not 
likely to be attempted in house operations, one can slip a 
chair, face down and well-padded, on the foot of the 
table, or an assistant standing between the patient's 



268 OPERATING ROOM 

thighs raises her legs over his shoulders, standing with his 
back to her, or one may elevate the foot of the table 
with blocks, boxes, or solid chairs, propping the other 
end to keep it from sliding. 

(14) The anesthesia set requires a pus basin, made 
from a large soap dish or a soup plate, and a cone for 
ether for the closed method (Fig. 54) made out of a towel 
and a folded newspaper; or for the open method or drop 



WS 



i 



t 



Fig. 54. — Closed method of anesthesia. 

method (Fig. 55) of either ether or chloroform a piece of 
flannelette over a tea or coffee strainer. Most anes- 
thetists would bring their gas-ether or gas-oxygen outfit 
with them. The nurse may use her own hypodermic 
syringe for stimulation. 

(15) The operation is rendered too dangerous if per- 
formed by gaslight or lamplight under ether, which is in- 
flammable and volatilizes in a long, continuous invisible 
train that connects by-and-by with the flame. 



IMPROVISED OPERATING ROOM IN A HUMBLE HOME 269 

(16) Daylight may be rendered equally diffuse by smear- 
ing Bon Ami on the lower half of the windows and at the 
same time obscuring them to the gaze of the passers-by. 

(17) Oilcloth and thick pads of old newspapers confined 
in thin old sheets or gauze will protect the furniture, 
table, blankets, etc., from blood, water, and iodin. 

(18) A stretcher is made by laying two square chairs 
face down on the floor, their feet meeting. The legs are 






Fig. 55. — Open method of anesthesia. 

very solidly spliced and a piece of board laid and fastened 
in the center, then the whole covered with blankets and 
draw-sheet. The upper ends of the chair or the top cross- 
piece make a secure handle. This stretcher stands at a 
good height by the bed for lifting the patient on or off 
with the aid of a folded sheet (Fig. 56). 

(19) If vaginal work is to be done a Kelly pad (Fig. 
57) is improvised as follows: Required, a blanket, old and 
soft; adhesive strips, 6 by 2 inches; a rubber sheet or a piece 



270 



OPERATING ROOM 



of oilcloth, 2 3 T ards by 1 yard; two hemostats; eight pieces 
of gauze bandage each 12 inches long. . Roll the blanket 




tightly and tie it in one long cylindric roll. Lay it on the 
farther long edge of the rubber and roll toward the 



IMPROVISED OPERATING ROOM IN A HUMBLE HOME 271 

nurse, about two turns. Divide into three equal parts, 
the middle part at least being 2 feet wide. Grasping the 
roll firmly, turn at the first third at a right angle. Do the 
same with the last third. This leaves a triangle outside 
each side of the "Kelly pad." Reduce these triangles 







Fig. 57. — Improvised Kelly pad. 



by folding to one-half their size, bring over the roll, inte- 
riorly, and fasten with adhesive, artery clamps, or, at the 
worst, safety-pins, in the oilcloth only, not through an 
expensive rubber. Let the apron hang over into the 
waste pail. The whole resembles a soldier's blanket on 
the march. 



272 OPERATING ROOM 

(20) For a bed operation always use an ironing-board 
or the leaf of an extension table on the bed-frame under 
the springs at the patient's hips. 

(21) If a nurse is far from her base of supplies, and has 
to improvise a gown in a hurry, it may easily be done as 
follows: Take one large sheet and fold the long edge 
over about 12 inches. Mark the center of this fold to go 
over the breast. Make plaits facing to the center all 
along this fold, reducing the gown in size to fit the shoulders 
with large safety-pins or bastings. Pin or stitch to the 
back of the neck two tapes each 12 inches long. Fold 
the whole in the uniform method, put up, and sterilize. 
On opening it, it is placed by the now scrubbed nurse, 
before her, so that the tapes are in position to be tied by 
any unscrubbed assistant, who then takes the very tip of 
the corner of the sheet, extended along her arm, and, as 
she pivots about, with her arm out as a lever, winds the 
fold around her arm so that it envelops it completely and 
is pinned to her back. A reverse swing puts the other 
corner in the same position. 

(22) Improvised masks are made as follows: A piece 
of gauze | yard square is, before the person scrubs, laid 
up on his chin. The lower two points are twirled and 
tied up on top of his head. The upper two corners are 
twirled and tied over and behind the ears. 

(23) A piece of gauze 1 yard square brought (doubled 
diagonally) from the back of the neck, barely escaping the 
tips of the ears and tied on the brow, with the central 
point tied in with it, makes a cool, serviceable cap. 

(24) A loose pyjama coat with a skirt made of a draw- 
sheet and put on backward makes a practical gown. 

(25) The cleansing operations preceding the surgeon's 
arrival take place the day before — taking down pictures 
and hangings, washing the walls with bichlorid after dust 
has settled, covering the carpet with thick papers or old 
sheets, or both, screening the window with cheese-cloth 
for ventilation, and, if there is not time to dismantle, 
hanging sheets over everything high and dusty. One 



IMPROVISED OPERATING ROOM IN A HUMBLE HOME 273 

great secret of modern surgical success is that everyone 
hastens so fast that there is no time for dust to fall into 
a wound nowadays. 

With modern facilities of travel and the increasing 
erection of hospitals, these conditions would likely exist 
only in the remote wilds or in a case of virulent contagion 
with complications. But every nurse should cultivate 
the power of improvisation, so as to save expense of every 
kind and in every place where the illness is even the 
slightest financial burden. 

18 



CHAPTER XXI 

A PLEA TO THE SUPERINTENDENT IN BEHALF 
OF THE OPERATING ROOM 

AXIOMS 

I. Consider that skill is worth more than money, and 
try to keep a capable official as supervisor of the operating 
room by giving her support in her just ambitions for her 
sphere of work. 

II. Keep the Board of Governors interested in the 
special need of the operating room, whether it be of an 
electric cautery, a new table with convenient adjustments, 
or larger sterilizers. 

III. Induce the auxiliary societies (in small institu- 
tions) to come and learn to fold gauze, so as to help build 
up large reserves of operating-room goods. • 

IV. Take the side of the workers in your own official 
family, and by learning what they need, and thinking 
and willing constantly, hypnotize the managers to buy it. 

V. Only sell sterile goods by the consent of the super- 
visor, who knows her limitations — (a) vacations; (6) 
breakdown of apparatus; (c) sick nurses, etc. Issue a 
report to the Medical Board monthly, showing all the 
sales of such goods. 

VI. When sterilizing goods for outside patients who 
intend to be operated on or confined at home, the price 
should be in proportion to the value which the supervisor 
bears to the institution, the time taken in the process, 
and the cost of the hospital equipment, all of which is 
special or technical; e. g., $3.00 is a fair price for steriliz- 
ing a suitcase of goods for an obstetric case when the 
patient can afford to have the services of the type of 
physician who demands those dressings. Where pa- 

274 



A PLEA TO THE SUPERINTENDENT 275 

tients are very poor they may be treated on the hospital 
wards, for part of which the municipality pays. 

VII. Encourage the formation of an operating-room 
library, with special works of reference on gross and 
minute anatomy, surgery, materia medica, vaccine and 
serum therapy, pathology, bacteriology, etc., including 
cinematograph, charts, skeleton, mannikin, and other ob- 
jects for demonstrating purposes/ In surgery, the text- 
books should vary according to the variety of work under- 
taken — orthopedics, eye, ear, nose and throat, general, 
gynecologic, etc. Very frequently a patient going home, 
pleased with his treatment and particularly interested 
in the spotless operating room, asks what he could give, 
and, instead of saying "money," ask for some books to 
better that service. 

VIII. When things are required for the operating 
room for some specific purpose get them immediately. 
Send an orderly as a special messenger. If these articles 
required could have been asked for previously, and were 
not, by some one's neglect, visit your wrath on the guilty 
one, but get them immediately none the less, so that the 
patient will not suffer. It would be wholesome to have the 
offender pay the messenger's carfare or the long-distance 
telephone expenses. 

IX. Give the supervisor and pupils time off to visit 
other hospitals where surgery is particularly well carried 
on, and make arrangements ahead to have them met and 
taken around to see the salient points for their education. 
This is to be counted to them as work and their expenses 
should be paid, but a detailed report of what they saw 
demanded of them. 

X. Consult the committee on surgical work, a part 
of the Medical Board, as to means of progress, and use 
all your energies to induce them to simplify technic and 
cut out unnecessary fads and fancies. 

XI. Become a member of the American Hospital 
Association and attend its meetings. Take an active 
part in the operating-room work discussions and learn from 



276 OPERATING ROOM 

others, also giving the benefit of your own experiences. 
Push the work of standardizing all operating-room technic. 

XII. In small village hospitals make a direct appeal for 
special articles to the people through the daily papers and 
the posting of lists in the hospital office, showing what 
articles are needed in the operating room. 

XIII. When the office is notified that such and such a 
case is coming in, notify the operating-room supervisor 
at once, so that, in the event of immediate operation, she 
has all her forces at her disposal; the most needed nurse's 
will not have just "gone off for their time" or some big 
cleaning task be just begun. Never defer giving the 
operating room any information. The Duke of Welling- 
ton said of the humid atmosphere of Scotland, "On a fair 
day, carry your umbrella; on a wet day, suit yourself," 
but often when we carry an umbrella on a damp day we 
do not need it, and often when in a state of semireadiness 
the dreaded event does not occur. 

XIV. Being a very small staff, the concentration of any 
rush of surgical work is more than doubly felt by the 
operating room, through not only the number of cases, 
but their dressings and sterilizing. To the superin- 
tendent, who is also directress of nurses, it must be 
urgently remarked that by adding to the operating-room 
staff in a rush at the expense of other wards much is 
really gained. It does not pay to confront any human 
being with an impossible task, and where a very robust 
young woman may stand ward work excellently, she may 
suffer unheard-of fatigue in the operating room due to 
(1) tiled floors, (2) steam-heated and steam-moistened air, 
(3) very long hours, and (4) stairs, in some hospitals, to 
supply rooms. Good, efficient service cannot be obtained 
from fatigued bodies and minds, but the higher the 
standard of our care of nurses, the more exacting should 
be our discipline. 

XV. Encourage the formation of an extensive reserve 
of goods. In a rather slack time, between seasons, or in 
a period of very good municipal health, every spare 



A PLEA TO THE SUPERINTENDENT 277 

moment should be utilized in making dressings, dressing 
covers, vaginal sets, etc., and the superintendent who 
would refuse to buy gauze or unbleached muslin for this 
purpose does not know her business. The poor patients 
are maintained by charity, and both those who can give 
charitable funds, and those who pay their own expenses 
have made their money by forethought and providence, 
and certainly, if they only knew, would make mock 
of any institution working on a narrow margin. These 
institutions are not commercial, not to be regarded as in 
any possible way self-supporting. It is the duty of the 
municipality to provide for its sick in the most efficient 
way by obtaining skilled officials and excellent materials. 
The cost of 100 yards or more of gauze or muslin do not 
come out of any special person's pocket, and yet, while 
giving that $2 or $15 is a relief to the man who thus per- 
forms his charitable duty, it is vastly more so to the 
strained mind of the anxious nurse who wants to feel 
that she is safe, no matter what emergency arises. True 
economy in a hospital is based on (1) getting a good 
quality of goods, (2) following them up to prevent steal- 
ing, burning, destruction. 

XVI. The laundry is responsible to the matron or 
housekeeper, who should be directly responsible to the 
superintendent of nurses. In a private home the laun- 
dress is not responsible to the man of the house. But 
either directly or indirectly though this may be, the 
laundry must pay special attention to all operating-room 
linens, and there should be a waiving of red tape to help 
the supervisor of the operating room get a special set of 
articles rushed through at any one time, or to have her 
otock collected and laundered oftener than the wards 
do. This requires rules and checking up. Operating- 
room stuff must be cleared out at all times in the laundry. 

XVII. Many times the superintendent is persona non 
grata in the operating room because he seems frigid and 
unsympathetic with the nursing staff, or too much in- 
clined to take charge of them and tell them what to do. 



278 OPERATING ROOM 

Again, sometimes a woman of loud voice or arrogant 
manner may seem to take charge of the whole operating 
room, surgeons included, creating a decidedly unpleasant 
atmosphere. It is occasionally possible that one whose 
duties are far from asepsis and vigilance in detail, un- 
mindful of the little niceties of position in the operating 
room, inadvertently bumps up against sterile tables in a 
way that would bring down a sharp reminder if it were 
done by only a pupil. All persons entering an operating 
room are subject to the will of the surgeon, and are in the 
presence of life and death. No visit should be made, 
then, unless its purport bears directly on the immediate 
event, and no conversation should take place except for 
the benefit of the case during that vital period. If, per- 
adventure, a visitor detects a nurse making an error, it 
should be corrected through the supervisor. 

XVIII. Politics, relating to the influence of one surgeon 
more than another, must not enter into a superintendent's 
policy. This is mentioned here since the surgeons usually 
bring the best paying cases to the hospital, and the oper- 
ating room fees are a source of revenue. A capable super- 
intendent is one who lives by the Ten Commandments 
and the Golden Rule. The official who can be strictly 
impartial to, all men, and yet provide them good satis- 
factory service is very valuable to the institution. 

XIX. It is very obvious to doctors and nurses if a 
superintendent visits the operating room only to see 
certain favorite surgeons operate, or to see certain fashion- 
able patients operated on. It causes discussion, mockery, 
and disrespect, and is based on partiality, an insidious foe 
to good administration. 

XX. The appointment of orderlies for this service is in 
some hospitals the duty of the superintendent, and should 
be a matter of extreme care, since they should be men of 
intelligence and good habits. They live on rather close 
footing with the nurses for ten hours a day, and they also 
must assist the surgeons in genito-urinary operations. 
While engaged and paid by one official, they work for 



A PLEA TO THE SUPERINTENDENT 279 

another, and might run to both with complaints. On 
being engaged they should be impressed by the super- 
intendent that they are entirely at the command of the 
operating-room supervisor as to duties, relief, hours, etc. 
There will be no trouble when they see perfect coopera- 
tion between the office and the operating room. 

XXI. The superintendent should visit the operating 
room at regular intervals, as the rest of the house, to see 
what repairs or improvements can be made, but at an 
hour suitable to the supervisor. He should also have a 
schedule for visiting the cases, but so arranged as to treat 
all in fairness. By showing a technical knowledge on 
some salient point and no ignorance of common things 
he fortifies his own position in the house. 



CHAPTER XXII 

THE CHOICE AND APPOINTMENT OF AN 
OPERATING-ROOM SUPERVISOR 

To have a superior type of woman in this position 
tells so strongly in the complete training of pupils that 
the boards cannot take too much care in their selection. 
Again, the services rendered the surgeons must be per- 
formed in such an impartial and efficient way to keep up 
the reputation of the institution that her character must 
be equalled by her ability. Possibly more than any 
other official she comes nearer to the superintendent of 
the institution, excepting always the chief executive of 
the nursing department, since her buying is technical, her 
department so fertile in revenue, and nursing in its com- 
moner sense all but eliminated. Nevertheless, she is 
first, last, and always a nurse. Her diploma reads identi- 
cally the same as any other nurse's. To avoid any possi- 
bility of disloyalty or friction she should work under the 
jurisdiction of the superintendent of nurses, to whose class 
or type she wholly belongs. 

The most important features in the make up of a fine 
supervisor are summed up as follows: 

(1) A good sound physique, and a rather practical, 
calm mind. 

(2) Presence of mind, determination, system in work- 
ing. 

(3) Dignity toward the pupils and a little aloofness 
from them always. 

(4) Good principles always lived up to, generosity of 
disposition, and a searching grasp of human nature. 

(5) Sympathy with the sick, especially with those 
overtaken by sudden accident or pain, and willing service 
in emergencies. 

280 



THE CHOICE AND APPOINTMENT OF A SUPERVISOR 281 

(6) Excellent education, much reading, and good 
manners. 

(7) Breadth of experience and wide observation, both 
of things professional and things mundane. 

If any woman in the world but a nurse were asked to 
measure up to all that she would quail. But many 
points have been omitted, and yet if a nurse fails to gain 
approval on any one of these things we magnify her 
failure instead of trying to help her to remedy it. 

However, in applying for a new position, the future 
supervisor presents the diploma of her training-school, 
her State license to wear U R. N." tacked on to her name, 
and, let it be here suggested, a genuine and sincere state- 
ment from her Alumnse Association, drawn up by a com- 
mittee from her own class, who know her better than any- 
one else. Think what an effect that would have on the 
present-day nurses! No hospital official should ever 
consider engaging supervisors who do not wear the 
R. N. It is the duty of each institution getting public 
moneys to assume its share of the responsibilities, created 
by its very existence, for the State Board, or Regents, 
who have systematized and caused to be accepted by the 
legislature an emblem of ability and character for all 
worthy applicants who have in their turn also carried out 
their own responsibilities to their school and to them- 
selves. Therefore, if equally stringent means were taken 
to encourage nurses daily to earn their future commenda- 
tion, it would remodel the whole internal working of the 
present training-school system. Furthermore, when a 
nurse voluntarily adopts a "specialty" like operating-room 
work, it is to be hoped, and not assumed but carefully 
determined, that (1) she is suited for it; (2) she will con- 
tribute to it some additions in invention or discovery; 

(3) she will not have first failed in other fields of nursing; 

(4) she will be a good model for pupils to study. 

But an applicant cannot demonstrate this at one or 
many interviews. It must be down in black and white. 
It is, therefore, here suggested that the State Boards 



282 OPERATING ROOM 

form a standard to which all who style themselves oper- 
ating-room supervisors must measure up, consisting of a 
test taken every three years, and embracing these features : 

(1) Previous records of skill, executive ability, character; 

(2) oral examination in newer materia medica, technic, 
etc.; (3) practical demonstrations in demonstrating to a 
pupil (a) aseptic technic; (6) making dressings; (c) making 
solutions, etc. 

The examiners should be surgeons and nurses in the 
van of surgery and nurses' practical affairs, also including 
instructors in pedagogics for nurses. There is just as 
much pedagogy required in teaching a nurse as in teaching 
literature or geometry. 

The applicant for any position should make a written 
request for an interview with the superintendent of nurses, 
enclosing copies, not the originals, of her degrees and 
letters of commendation. Meanwhile she will have 
made inquiries from every source at her command, 
personal and professional, about the town, the people, 
the industries, the means of transit, as well as the hospital 
with its house officials and staff of surgeons. For this 
purpose medical directories and State reports of hospitals 
and training-schools classified on cold, hard facts are 
available to every one. 

When the superintendent of nurses has had a searching 
and satisfactory interview with the nurse supervisor, who 
presents now her true, original letters, she visits with her, 
by previous appointment, the office of the superintendent, 
who is entitled to be thoroughly posted as to the qualifica- 
tions of such an important applicant. From his stand- 
point again a searching talk bearing on the business rela- 
tions of the operating room to the institution should be 
held, probably placing before the nurse a few examples 
of "political" difficulties that arose in the past and asking 
her how she would meet them. It is not, however, for 
the superintendent to instruct, appoint, or command this 
nurse. That would be expressed by him to her only 
through the conferences he would later hold with the 



THE CHOICE AND APPOINTMENT OF A SUPERVISOR 283 

superintendent of nurses. Of course, in a busy staff it 
would be impossible for the latter to be always present, 
but when addressing the supervisors anywhere the 
superintendent should, by courtesy, always imagine her to 
be there, and never say anything that he would not say 
if she were there. As men usually deal with men, he 
would not give orders to a fireman "over the head" of the 
engineer. The comparison may seem crude, but the 
principle of responsibility is the same. He is not a nurse, 
and there are no diplomas yet issued for superintendents — 
speed the day! — with all due respect to the many excellent 
superintendents who have graced their gubernatorial 
chair in metropolitan institutions with a patience, execu- 
tive skill, and tact almost unbelievable. 

Assuming that the two chief officials agree about this 
applicant, an appointment should be made that she could 
meet the committee on surgical business, a flexible and 
fairly chosen live body of men in the Medical Board. 
These men should question the nurse until they are 
themselves satisfied that she has a good record and 
knows her business; even if they have to take her to the 
operating room and make her demonstrate difficult work 
there. 

When all these persons agree, and the nurse finds the 
place suitable as far as she knows, the appointment is 
ratified by the Board of Governors in a formal letter, 
since they are responsible for her salary and, at the close 
of an engagement that was very efficient on her part, for 
her record. Boards are continuous in existence, but a 
superintendent of nurses, in small hospitals, frequently 
changes her position, and her office need not be bound by 
any obligations created by a predecessor. Obligations 
must be in black and white and ratified by a responsible 
person or body, but in courtesy to one's own profession 
many are continued, that make for the well-being of some 
workers. 

In some states, like Maryland, certain hospital officials 
are bonded, and then given great responsibilities with, 



284 OPERATING ROOM 

naturally, greater freedom. But where no hostages are 
given, no obligations should be incurred. 

An operating-room supervisor should make up her 
mind as to what she wants, what she can have, and how 
to make the best of what is offered; finding this within 
her scope, she naturally accepts. She should get accu- 
rate, reliable information about the length of her vaca- 
tions, with or without pay, the hours for work and recrea- 
tion, her other duties, if any, in the institution outside 
her own sphere, her relief, her private quarters, and all 
points relating to the management of the operating room; 
for example, the authority of the Medical Board or its 
committees, the number of surgeons, the nature and 
average amount of cases, the number of pupils at one 
time, the methods of caring for night cases, etc. 

Business registries, run for financial reasons alone, are 
not the best sources of information for either the hospitals 
or the nurses, since they thrive on the number of "deals" 
they close, and do not comprehend the ethics and technic 
of the profession. Yet there are some very excellent 
registries conducted on that basis. 

School registries do not make enough effort to promote 
this business side of their profession, on the other hand. 
While emanating from the finest hospitals, where natur- 
ally one would expect to find good young executives "in 
the bud," they simply busy themselves with sending 
nurses out to private practice. 

A model registry should be that conducted by nurses 
for nurses, for executive, educational, operating, district, 
school, and private positions. But these fail terribly at 
times through being entirely too ethical. Few people 
can write a really honest testimonial. The nurses who 
wish to do institutional work present insincere docu- 
ments, which pass the censor, whether through indiffer- 
ence or a mistaken desire to be ethical. It is time to ex- 
pose this false free masonry which has not put the nurses 
through any real test. It takes a very great deal of ex- 
pense and time to verify testimonials, and that is what a 



THE CHOICE AND APPOINTMENT OF A SUPERVISOR 285 

registry is paid to do. But it is often neglected, with the 
result that invalid, irritable, unskilled failures are foisted 
on busy, strenuous high-grade hospitals, to the disgust of 
all who try charitably, in spite of first impressions, to give 
them time "to make good." 

Some hospitals make it an unvarying rule never to 
take on an official or employee who is at the time "out of 
a job." While this has its exceptions, it will be found, 
in the main, to work well. 

There should be a period set in all business arrange- 
ments, as a "notice" for the termination of the contract, 
to avoid irregularities in paying salaries, and sudden 
upheavals of departure, a month being none too long to 
give a hospital a sufficient chance to find a good super- 
visor, while, if the nurse were at fault, it might take her 
much longer to find a position, and yet she could imme- 
diately do private nursing, which compensates. 

One thing most of all to be avoided is "one-man" ap- 
pointments and "one-official" pulls. It is not a healthy 
condition of affairs where a nurse obtains a position 
through the influence of any man with whom she will 
afterward be closely identified in the operating room. 
It creates a feeling of indebtedness that she wishes to 
pay off. She then becomes unjust to other surgeons, and 
partiality is an insidious and heinous crime, burrowing its 
filthy roots through the whole structure. It would be 
no harm for an orthopedic surgeon to recommend some 
clever nurse he knew to an eye and ear operating room 
where he did not work. Similarly with the house staff, 
if the officials cannot agree that one applicant is worthy, 
better sacrifice her than the serenity that should exist 
between the heads, unless the objector can be proved 
wrong by overweight of evidence. Neither is it healthy 
to have undue interest on behalf of any one member of 
the Board of Governors in any supervisor. A little 
creeping up of her salary now and again, or longer 
vacations with pay will create a jealousy among the 
others in which her life will naturally be unhappy. A 



286 OPERATING ROOM 

nurse should always be approved or condemned by her 
peers. 

This may be happily solved some day by the American 
Hospital Association. In it is a way out of most of our 
difficulties. If the position of operating-room nurse be 
standardized in all its features, and if these nurses also 
meet specially in committee, to learn from one another, 
study exhibits, hear lectures from the greatest surgeons, 
and improve their minds, the hospitals engaging them will 
be sure of much of their hoped-for aim. 



THE GOSPEL OF WORK 



A MODERN NURSE'S QUINTALOGUE 



I. Want something. 
II. Know what you want. 

III. Determine to get it. 

IV. Think the best way to get it. 

V. Work to get it, and as fast as you're 
knocked down, get up again and go on. 

— Anonymous. 



287 



INDEX 



Abscess of brain, instruments for 
operation, 192 
pharyngeal, 192 

Acumen, business, 22, 71 

Adenoids, removal of, instru- 
ments for, 191 

Adhesive, how to sterilize, 150 

Advancement, 88 

Albee electro-operative bone set, 
76 

Alcohol, denatured, 232 
bonds for, 232 

Aluminum acetate solution, 138 

Ambulance, 71, 72 
bags, 70 

American Hospital Association, 
275 

Amputation of breast, instru- 
ments for, 193 

Anatomy, 29 

Anesthesia, rectal, 63 
spinal, 63, 248 

Anesthetics, local, 142 
special, 63 

Anesthetists, 55, 57, 65, 127 
nurse, 58 

Aneurysm needles, 201 

Appendectomy, instruments for, 
196 

Applicators, 161 

Argyrol, 142 

Aristol pledgets, 160 
19 



Artificial respiration, Sylvester's 

method, 249 
Asepsis, 114 

breaks in, 128 
Attendants, health of, 130 
Autoclaves, 106 
Axioms, 274 

Bandaging, 160 

Beck nasal packing bags, 189 

Bed, Gatch, 44, 49 

Bichlorid of mercury solutions, 

140 
Binder, breast, 193, 221 

Scultetus, 219, 220 

T-, how to make, 162, 219 
Bistoury, 205 
Blanket warmer, 110 
Blankets, 228 
Blood, transfusion of, 244 
Blood-letting, 246 
Blood-serum, injection of, 243 
Bone, transplantation of, 265 
Bone-wax, 138 
Bore of needles, 151 
Boric acid solution, 139 
Bottles, care of, 134 
Bougies, 146 
Bow-legs, 250 
Bradford frame, 252 
Brain, abscess of, instruments for 

operation, 192 

289 



290 



INDEX 



Brandy, 232 

Breast, amputation of, instru- 
ments for, 193 
binder, 193, 221 
funnel, 250 

Buck's extension, 253 

modified, for hip disease, 265 

Bureau of Standards and Sup- 
plies, 231 

Burns, sterilized linen for, 229 

Business acumen, 22, 71 

Button, empyema, 196 
Murphy, 73 

Buying for the operating room, 
230 

Canula, 158 

Canule a chemise, 158 

Caps, 116, 221 

Carrel-Dakin antiseptic, 136 

Cataract operation, instruments 

for, 188 
Catgut, 133 

chromicized, 137 

iodized, 137 

preparation of, 137 
Catheters, 146 

silk, 147 
Cesarean section, instruments for, 

202 
Cholecystectomy, instruments 

for, 198 
Cholecystotomy, instruments 

for, 198 
Choledochotomy, instruments 

for, 198 
Chute, laundry, 27 
Clean nurse, 123 
Cloth retractors, 160 
Club-foot, 252 
Cocain, 142 
Cold cream, hospital, 152 



Colostomy bag, 204 
Contagion, 131 
Covers for dressings, 116 
Cubic centimeter, 154 
Curettage, instruments for, 205 
Cysts, evacuation of, 99 

Dampness of dressings, 115 

Dark room, 95 

Details in nursing, 80 

Deterioration, 63 

Diagnosis, surgical, terms used 

in, 163 
Dietetian, 70 
Discipline, 78 
Dislocation of hip, congenital, 

250 
Dissection, 70 
Distillation, 107 
Donor, 245 
Dorsal position, 50 
Draughts, forced, 92 
Dressing-rooms, nurses', 102 
Dressings, 22 

covers for, 116 

dampness of, 115 
Drop-forged instruments, 68 
Dusting, 23, 127 

Ear, radical operation on, in- 
struments for, 190 

Eight-hour duty, 32 

Electrical apparatus, 97 

Electricity, for sterilizing, 110 

Electrodes, 186 

Elevators, 102 

"Emanations" of radium, 101 

Emergency cases, 131 
orders, 233 

Empyema button, 196 

operation for, instruments, 194 

Engineer, 46, 106 



INDEX 



291 



Enucleation of eye, instruments 
for, 191 

Errors, detecting, 106, 109, 110, 
118 
in technic, 122 

Ethical relation, 87 
Eye, enucleation of, instruments 
for, 191 

pads, 160 

Faults, common, 81 

Filiforms, 146 

Filters, 105 

Fire-drill, 102 

Fistula in ano, operation for, 
instruments, 207 

Fixation forceps, 188 

Flasks, Florentine, 139 

Flat-foot, 252 

adhesive plaster strapping for, 
262 

Floors, 110, 129 

Florentine flasks, 139 

Folding gowns, 226 
linen, 225 

Forceps, 68 
fixation, 188 

Formaldehyd, 141 

Formalin, 141 

Fracture table, 261 

Fracture-box, 263 

Freezing of specimens, 148 

Frontal sinus operation, instru- 
ments for, 189 

Fumigation, 93 

Funnel breast, 250 

Gant pad, 208 

Gastrectomy, instruments for, 

200 
Gastro-enterostomy forceps, 199 

instruments for, 200 



Gastrostomy, instruments for, 

200 
Gatch bed, 44, 49 
Gauze, iodoform, 136, 137 

oxygen, 59 
Genito-urinary work, nurse's 

presence at, 33, 46 
Genu valgum, 250 

varum, 250 
Gigli saw, 185 

Glass syringes, sterilization of, 151 
Glasses, 116 
Gloves, rubber, 144 
with holes, 134 
Glove-tree, 144 
Gown covers, 225 
Gowns, folding of, 226 
Grafting, skin-, instruments for, 

193 
Greeley units for hypodermic use, 

54 
Gutta-percha tissue, 143 

Hallux valgus, 251 

varus, 251 
Halsted's silver foil, 149 
Hand lotion, hospital, 152 
Handling goods from jar, 124 
Harrison law, 142 
Head operations, instruments for, 

185 
Health of attendants, 130 
Hemolysis, 244 
Hemorrhoidectomy, instruments 

for, 206, 207 
Hernia knife, 204 
Herniotomy, instruments for, 203 
Hints, general, 71 
Hip, congenital dislocation, 250 

disease, 251 

modified Buck's extension 
for, 265 



292 



INDEX 



Home, improvised operating 

100m in, 266 
Hopper room, 113 
Horsehair, 138 

Hospital Bureau of Standards 
and Supplies, 231 

cold cream, 152 

hand lotion, 152 
Hypodermic use, Greeley units 

for, 54 
Hypodermoclysis, 242 
Hysterectomy, instruments for, 

200 

Impartiality, 30 
Infusion, intravenous, 234 

thermometer, 238 
Instruments, care of, 149 

contaminated, 128 

for various operations, 185 
Intravenous infusion, 234 
Iodoform gauze, 136, 137 

thermometer, 238 
Iridectome, 188 

Jars, care of, 134 

Jugular operation following sinus 

thrombosis, instruments for, 

190 
Jury-mast, 263 

Kangaroo tendon, 138 
Kelly pad, improvised, 271 
Kidney position, 50 
Knee-chest position, 51 
Knee-swell, 96 
Knives, 68 
Knock-knee, 250 
Kyphosis, 251 

Labarraque's solution, 229 
Lane's bone plates, 75 



Laparotomy gowns, 220 

sheets, 222 

stockings, 220 
Laundry chute, 27 
Law, Harrison, 142' 
Leg rolls, 159 
Legal phases, 81 
Ligatures, 68 
Linen, 217 

folding of, 225 

for isolated cases or dirty dress- 
ings, 229 
Lithotomy position, 51 
Lordosis, 251 
Lorenz operation, 256 
Lumbar puncture, 247 
Lycopodium powder, 146 

Mache units of radium, 101 
Mangle felt, 259 
Masks, 116, 222 
Mastoid dressing, 157 

operations, instruments for, 
186 

tips, 157 
Mayo's gall-stone scoop, 199 
Medical Board, 18, 95, 119, 283 
Messengers, special, 233 
Metric System, 153 
Michell clips, 198 • 
Mortise-lock, 68 
Moving-pictures, 34 
Murphy button, 73 

Nasal septum, submucous resec- 
tion, instruments for, 188 

Needles, bore of, 151 
slip-ons of, 68 
testing, 73 
threading, 67 

Nephrectomy, instruments for, 
203 



INDEX 



293 



Nephrotomy, instruments 
203 

Nitrate of silver, 141 
Nomenclature, 209 
Novice, 20, 21 

Novocain, 142 

Orderly, 23, 57, 127, 130 

Orientation, 188 
Orthopedic surgery, 250 

tables, 262 
Osteoclast, 251 
Oxygen gauge, 59 

Packing covers, 225 

making of, 160 
Pad, Gant, 208 

Kelly, improvised, 271 
Pads, eye, 160 

special table, 99 
Pathologic tissue, 164 
Perineorrhaphy, instruments 

206 
Petticoated tube, 158 
Pharyngeal abscess, 192 
Pheasants' feathers, 192 
Phlebotomy, 241, 246 
Plaster bandages, 257 

of Paris, 257 
Platinum, 75, 156 
Pledgets, 160 
Plumbing, 96 
Politzer bag, 196 
Position, dorsal, 50 

kidney, 50 

knee-chest, 51 

Sims', 51 

Trendelenburg, 41, 51 
Potain's aspirator, 237 
Pott's disease, 252 
" Preparedness," 77 



for, Pulmotor, 64 

Puncture, lumbar, 247 

Radium, 101 

Rectal anesthesia, 63 
specula, 206 

Respiration, artificial, Sylves- 
ter's method, 249 

Retractors, cloth, 160 

Rotation of service, 17 

Routine, 82 

Rubber gloves, 144 
tissue, 143 
tubing, 146 
utensils, care of, 150 



Safety devices, 109 
Saline, cloudy, 108 

making, 139 

selling, 88 
Saw, Gigli, 185 
for, Sayre's suspension apparatus, 

263 
Scholarships, 32 
Scoliosis, 252 
"Scratchier," 265 
Scultetus binder, 219, 220, 
Self-government, 33 
Serum, 64 

blood-, injection of, 243 
" Setting-up," 38 
Shoes, 130 
Silk catheters, 147 

surgeons', 138 
Silkworm-gut, 138 
Silver leaf, 149 

nitrate, 141 
Sims' position, 51 
Skin-grafting, instruments for, 

193 
"Slip-ons" (of needles), 68 



294 



INDEX 



Solution, Labarraque's, 229 

Specimens, freezing of, 148 

importance of, 44 
Specula, rectal, 206 
Sphygmomanometer, 246 
Spinal anesthesia, 63, 248 
Splay foot, 250 
Sponges, small, 159 
Square measure, 153 
Stains, how to remove, 228 
Steam-pressure, 106 
Sterilization, complete, tests for, 
107 

of adhesive, 150 

of rubber gloves, 144 

of vaselin, 152 
Sterilizing room, 104 
Stovain, 248 
Strabismus hook, 191 

operation for, instruments for, 
190 
Stretchers, 99 

improvised, 269 
" Submucous," 188 
Suits, purchase of, 229 
Superintendent, plea to, 274 
Supervisor, choice and appoint- 
ment, 280 
Supply-room, 162 
Surgeons' silk, 138 
'Surgical diagnosis, terms used in, 

163 
Sutures, 67, 75 
Sylvester method of artificial 

respiration, 249 
Syringes, 64 

glass, sterilization of, 151 



Table pads, special, 99 

tonsil, 99 
Tact, 30 



Talipes, 252 

equinus, 252 

planus, 252 

valgus, 252 

varus, 252 
Tampon canula, 158 
Tampons, 159 
Tape stickers, 161 
Tap-water, 135 
T-binder, how to make, 162, 

219 
Teaching, 79 
Technic, errors in, 122 
Telephone, 22, 48 
Temperature, 92 
Tendon, kangaroo, 138 
Terms used in surgical diagnosis, 

163 
Testing needles, 73 
Thermometer, infusion, 238 
Thiersch's solution, 136 
Threading needle, 67 
Thrombosis, 235 
Thrombus, 235 
"Tips," mastoid, 157 
Tonsil table, 99 
Tonsils, removal of, instruments 

for, 191 
Towels with holes, 134 
Trachelorrhaphy, instruments 

for, 206 
Tracheotomy, instruments for, 
192 

tubes, 151 
Trade names, 232 
Training in operating-room, 17, 

31 
Transfusion, 244 
Transplantation of bone, 265 
Trendelenburg position, 41, 51 
Triple strength saline, 239 
Twigs, 47 



INDEX 



295 



Vaginal sheets, 223 
Vaselin, sterilization of, 152 
Venesection, 246 
Ventilation, 90 
Viscera forceps, 197 
Volume, metric units of, 154 
Vulsellum forceps, 201 



Walls, 129 
Waste receptacles, 101 
Whisky, 232 
"Whistle," 208 

Workrooms, 111 

Zeiss light, 99 



Books for Nurses 



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i2mo volume of 311 pages, fully illustrated. Cloth, $1.50 net. 

Goodnow's First-Year Nursing 2d edition 

Miss Goodnow's work deals entirely with the practical side of 
first-year nursing work. It is the application of text-book 
knowledge. It tells the nurse how to do those things she is called 
upon to do in her first year in the training school — the actual 
ward work, 

First-Year Nursing. By Minnie Goodnow, R. N. f formerly Super- 
intendent of the Women's Hospital, Denver. wmoof 354 pages, 
illustrated. Cloth, $1.50 net. 



Aikens' Hospital Management 

This is just the work for hospital superintendents, training- 
school principals, physicians, and all who are actively inter- 
ested in hospital administration. The Medical Record says: 
"Tells in concise form exactly what a hospital should do 
and how it should be run, from the scrubwoman up to its 
financing." 

Hospital Management. Arranged and edited by Charlotte A. 
AlKENS, formerly Director o Sibley Memorial Hospital, Washing- 
ton, D. C. i2mo of 488 pages, illustrated. Cloth, $3.00 net 

Aikens' Primary Studies new (3 d) edition 

Trained Nurse and Hospital Review says: s 'It is safe to say 
that any pupil who has mastered even the major portion of 
this work would be one of the best prepared first year pupils 
who ever stood for examination. " 

Primary Studies for Nurses. By Charlotte A. Aikens, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
471 pages, illustrated. Cloth, $1.75 net 

Aikens' Training-School Methods and 
the Head Nurse 

This work not only tells how to teach, but also what should 
be taught the nurse and how much. The Medical Record says? 
*' This book is original, breezy and healthy." 

Hospital Training-School Methods and the Head Nurse. By Char- 
lotte A. Aikens, formerly Director of Sibley Memorial Hospital.; 
Washington, D. C. 121110 of 267 pages, Cloth, $1.50 net 

Aikens' Clinical Studies NEW (2d) EDITION 

This work for second and third year students is written on the 
same lines as the author's successful work for primary stu- 
dents. Dietetic and Hygienic Gazette says there * ' is a large 
amount of practical information in this book." 

Clinical Studies for Nurses. By Charlotte A. Aikens, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
569 pages, illustrated Cloth, $2.00 net 



Bolduan and Grund's Bacteriology 

The authors have laid particular emphasis on the immediate 
application of bacteriology to the art of nursing. It is an 
applied bacteriology in the truest sense. A study of all the 
ordinary modes of transmission of infection are included. 

Applied Bacteriology for Nurses. By Charles F. Bolduan, M. D., 
Assistant to the General Medical Officer, and Marie Grund, M.D., 
Bacteriologist, Research Laboratorv, Department of Health, City of 
New York. i2mo of 166 pages, illustrated. Cloth, $1.25 net. 

Fiske's The Body anew idea 

Trained Nurse and Hospital Review says "it is concise, well- 
written and well illustrated, and should meet with favor in 
schools for nurses and with the graduate nurse.' ' 

Structure and Functions of the Body. By Annette Fiske, A. M., 

Graduate of the Waltham Training School for Nurses, Massa- 
chusetts. i2mo of 221 pages, illustrated. Cloth, $1.25 net 



NEW (3d) EDITION 



Beck's Reference Handbook 

This book contains all the information that a nurse requires 
to carry out any directions given by the physician. The 
Montreal Medical Jour?ial says it is " cleverly systematized and 
shows close observation of the sickroom and hospital regime. 59 

A Reference Handbook for Nurses. By Amanda K. Beck, Grad- 
uate of the Illinois Training School for Nurses, Chicago, 111* 
32010 volume of 244 pages. Bound in flexible leather, $1.25 net. 

Roberts' Bacteriology & Pathology 

This new work is practical in the strictest sense. Written 
specially for nurses, it confines itself to information that the 
nurse should know. All unessential matter is excluded. The 
style is concise and to the point, yet clear and plain. The text 
is illustrated throughout. 

Bacteriology and Pathofogy for Nurses. By Jay G. Roberts, Ph. G,, 

M. D., Oskaloosa, Iowa, nmo of 206 pages, illustrated. $1.25 net. 



DeLee's Obstetrics for Nurses IZ™ 

Dr. DeLee's book really considers two subjects — obstetrics 
for nurses and actual obstetric nursing. Trained Nurse and 
Hospital Review says the "book abounds with practical 
suggestions, and they are given with such clearness that 
they cannot fail to leave their impress." 

Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of 
Obstetrics at the Northwestern University Medical School, Chicago. 
i2mo volume of 508 pages, fully illustrated. Cloth, $2.50 net. 

Davis' Obstetric & Gynecologic Nursing 

NEW (4th) EDITION 

The Trained Nurse and Hospital Review says: " This is one 
of the most practical and useful books ever presented to the 
nursing profession." The text is illustrated. 

Obstetric and Gynecologic Nursing. By Edward P. Davis, M. D., 
Professor of Obstetrics in the Jefferson Medical College, Philadel- 
phia, i-jmo volume of 480 pages, illustrated. Buckram, $1.75 net 

Macfarlane's Gynecology for Nurses 

NEW (2d) EDITION 

Dr. A. M. Seabrook, Woman's Hospital of Philadelphia, says: 
" It is a most admirable little book, covering in a concise but 
attractive way the subject from the nurse's standpoint.' ' 

A Reference Handbook of Gynecology for Nurses. By Catharine 
Macfarlane, M. D., Gynecologist to the Woman's Hospital of Phila- 
delphia. 32mo of 156 pages, with 70 illustrations. Flexible leather,, 
$1.25 net. 

Asher's Chemistry and Toxicology 

Dr. Asher's one aim was to emphasize throughout his book 
the application of chemical and toxicologic knowledge in the 
study and practice of nursing. He has admirably succeeded. 

i2mo of igo pages. By Philip Asher, Ph. G., M. D., Dean and Pro- 
fessor of Chemistry, New Orleans College of Pharmacy. Cloth, 
$1.25 net. 



Aikens' Home Nurse's Handbook 

The point about this work is this: It tells you, and shows you 
just how to do those little things entirely omitted from other 
nursing books, or at best only incidentally treated. The 
chapters on "Home Treatments" and "Every-Day Care of 
the Baby/' stand out as particularly practical. 

Home Nurse's Handbook. By Charlotte A. Aikens, formerly Di- 
rector of the Sibley Memorial Hospital, Washington, D. C. i2mo of 
276 pages, illustrated. Cloth. $1.50 net 

Eye, Ear, Nose, and Throat Nursing 

This book is written from beginning to end for the ?iurse. You 
get antiseptics, sterilization, nurse's duties, etc. You get an- 
atomy and physiology, common remedies, how to invert the 
lids, administer drops, solutions, salves, anesthetics, the 
various diseases and their management. New {2d) Edition, 

Nursing in Diseases of the Eye s Ear, Nose and Throat. By the 
Committee on Nurses of the Manhattan Eye, Ear and Throat Hospital. 
i2mo of 291 pages, illustrated. Cloth, $1.50 net 

Paul's Materia Medica NEW w> edition 

In this work you get definitions — what an alkaloid is, an in- 
fusion, a mixture, an ointment, a solution, a tincture, etc. 
Then a classification of drugs according to their physiologic 
action, when to administer drugs, how to administer them, 
and how much to give. 

A Text-Book of Materia Medica for Nurses. By George P. Paul.M.D., 

Samaritan Hospital, Troy, N. Y. i2mo of 282 pages. Cloth, $1.50 net 

Paul's Fever Nursing new 00 edition 

In the first part you get chapters on fever in general, hygiene, 
diet, methods for reducing the fever, complications. In the 
second part each infection is taken up in detail. In the third 
part you get antitoxins and vaccines, bacteria, warnings of 
the full dose of drugs, poison antidotes, enemata, etc. 

Nursing in the Acute Infectious Fevers. By George P. Paul, M. D. 
i2moof 275 pages, illustrated. Cloth, $1.00 net 



McCombs' Diseases of Children for Nurses 

NEW (2d) EDITION 

Dr. McCombs , experience in lecturing to nurses has enabled 
him to emphasize ju st those points that nurses most need to know. 
National Hospital Record says: "We have needed a good 
book on children's diseases and this volume admirably fills 
the want." The nurse's side has been written by head 
nurses, very valuable being the work of Miss Jennie Manly. 

Diseases of Children for Nurses. By Robert S. McCombs, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo 
of 470 pages, illustrated. Cloth, $2.00 net 



NEW (2d) EDITION 



Wilson's Obstetric Nursing 

In Dr. Wilson's work the entire subject is covered from the 
beginning of pregnancy, its course, signs, labor, its actual 
accomplishment, the puerperium and care of the infant. 
America?! Journal of Obstetrics says: il Every page empa sizes 
the nurse's relation to the case." 

A Reference Handbook of Obstetric Nursing. By W. Reynolds 
Wilson, M.D., Visiting Physician to the Philadelphia Lying-in Char- 
Sty., samo of 355 pages, illustrated. Flexible leather, $1.25 net. 



NEW (9th) EDITION 



American Pocket Dictionary 

The Trained Nurse and Hospital Review says: "We have 
had many occasions to refer to this dictionary, and in every 
instance we have found the desired information." 

American Pocket Medical Dictionary. Edited by W. A. Newman 
Dorland, A. M., M. D., Loyola University, Chicago. Flexible 
leather, gold edges, $1.00 net; with patent thumb index, $1.25 net. 



THIRD 
EDITION 



Lewis' Anatomy and Physiology 

Nurses Joarnal of Pacific Coast says "it is not in any sense 
rudimentary, but comprehensive in its treatment of the sub- 
jects. " The low price makes this book particularly attractive. 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., Lec- 
turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay 
City, Mich. i2mo of 326 pages, 150 illustrations. Cloth, $1.7? net 



Bohm & Painter's Massage 

The methods described are those employed in Hoffa's Clinic 
— methods that give results. Every step is illustrated, showing 
you the exact direction of the strokings. The pictures are 
large. You get the technic used in Professor Hoffa's Clinic. 

Octavo of 91 pages, with 97 illustrations. By Max Bohm, M. D., 
Berlin, Germany. Edited by Charles F. Painter, M. D., Professor 
or Orthopedic Surgery, Tufts College Medical School, Boston. 

Cloth, $1.75 net 



SECOND 
EDITION 



Grafstrom's Mechanotherapy 

Dr. Grafstrom gives you here the Swedish system of mechan- 
otherapy. You are given the effects of certain movements, 
gymnastic postures, medical gymnastics, general massage 
treatment, massage for the various conditions. The illustra- 
tions are full-page line drawings. 

Mechanotherapy (Massage and Medical Gymnastics). By Axel V. 
Grafstrom, B. Sc, M. D., Attending Physician Gustavus Adolphus 
Orphanage, Jamestown, New York. i"6mo of 200 pages. 

Cloth, $1.25 net 

Friedenwald and Ruhrah's Dietetics for 

iNlirSeS NEW (3d) EDITION 

This work has been prepared to meet the needs of the nurse, 
both in training school and after graduation. American Jour- 
nal of Nursing says it "is exactly the book for which nurses 
and others have long and vainly sought." 

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor of 
Diseases of the Stomach, and John Ruhrah, M.D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
i2mo volume of 431 pages. Cloth, $1.50 net 



FOURTH 
EDITION 



Friedenwald & Ruhrah on Diet 

This work is a fuller treatment of the subject of diet, pre- 
sented along the same lines as the smaller work. Everything 
concerning diets, their preparation and use, coloric values, 
rectal feeding, etc., is here given in the light of the most re- 
cent researches. 

Diet in Health and Disease. By Julius Friedenwald, M.D., and 
John Ruhrah, M.D. Octavo volume of 857 pages. Cloth, $4.00 net 



Pyle's Personal Hygiene NEW ( 6t h) edition 

Dr. Pyle's work discusses the care of the teeth, skin, com- 
plexion and hair, bathing, clothing, mouth breathing, catch- 
ing cold; singing, care of the eyes, school hygiene, body 
posture, ventilation, heating, water supply, house-cleaning, 
home gymnastics, first-aid measures, etc. 

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., 

Wills Eye Hospital, Philadelphia. i2mo, 543 pages of illus. $1.50 net 

Galbraith's Personal Hygiene and Physical 
Training for Women illustrated 

Dr. Galbraith' s book tells you how to train the physical pow- 
ers to their highest degree of efficiency by means of fresh air, 
tonic baths, proper food and clothing, gymnastic and outdoor 
exercise. There are chapters on the skin, hair, development 
of the form, carriage, dancing, walking, running, swimming, 
rowing, and other outdoor sports. 

Personal Hygiene and Physical Training for Women. By Anna M. 
Galbraith, M.D., Fellow New York Academy of Medicine. nmo of 
371 pages, illustrated. Cloth, $2.00 net 

Galbraith's Four Epochs of Woman's Life 

This book covers each epoch fully, in a clean, instructive way, 
taking up puberty, menstruation, marriage, sexual instinct, 
sterility, pregnancy, confinement, nursing, the menopause. 

The Four Epochs of Woman's Life. By Anna M. Galbraith, M. D. 
With an Introductory Note by John H. Musser, M. D., University of 
Pennsylvania. i2mo of 247 pages. Cloth, $1.50 net 

Griffith's Care of the Baby NEW { **> edition 

Here is a book that tells in simple, straightforward language 
exactly how to care for the baby in health and disease ; how 
to keep it well and strong; and should it fall sick, how to 
carry out the physician's instructions and nurse it back to 
health again. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Univers- 
ity of Pennsylvania. i2mo of 458 pages, illustrated. Cloth, $1.50 net 



Aikens' Ethics for Nurses just ready 

This book emphasizes the importance of ethical training. It 
is a most excellent text-book, particularly well adapted for 
classroom work. The illustrations and practical problems 
used in the book are drawn from life. 

Studies in Ethics for Nurses. By Charlotte A. Aikens, formerly 
Superintendent of Columbia Hospital, Pittsburg. i2mo of 318 pages. 

Cloth, $1.75 net. 

Goodnow's History of Nursing ready soon 

Miss Goodnow's w r ork gives the main facts of nursing history 
from the beginning to the present time. It is suited for class- 
room work or postgraduate reading. Sufficient details and 
personalities have been added to give color and interest, and 
to present a picture of the times described. 

History of Nursing. By MINNIE Goodnow, R.N., formerly Super- 
intendent of the Women's Hospital, Denver. i2mo of 300 pages, 
illustrated. 



READY 
SOON 



Berry's Orthopedics for Nurses 

The object of Dr. Berry's book is to supply the nurse with a 
work that discusses clearly and simply the diagnosis, prog- 
nosis and treatment of the more common and important ortho- 
pedic deformities. Many illustrations are included. The 
work is very practical. 

Or;ho?edic Surgery for Nurses. By John McWilliams Berry, 
M.D., Clinical Professor of Orthopedics and Rontgenology, Albany 
Medical College. i2mo of 100 pages, illustrated. 



Whiting's Bandaging 



This new work takes up each bandage in detail, telling you — 
and showing you by original illustrations— just how each 
bandage should be applied, each turn made. Dr. Whiting's 
teaching experience has enabled him to devise means for over- 
coming common errors in applying bandages. 

Bandaging. By A. D. Whiting, M.D., Instructor in Surgery at the 
University of Pennsylvania. 121110 of 151 pages, with 117 illustra- 
tions. Cloth, $1.25 net. 

10 



Hoxie & Laptacfs Medicine for Nurses 

Medicine for Nurses and Housemothers. By George 
Howard Hoxie, M. D., University of Kansas; and 
Peaki, L. Laptad. 12mo of 351 pages, illustrated. 
Cloth, $1.50 net. New (2d) Edition. 

This book gives you information that will help you to carry out the 
directions of the physician and care for the sick in emergencies. It 
teaches you how to recognize any signs and changes that may occur be- 
tween visits of the physician, and, if necessary, to meet conditions until 
the physician's arrival. 

Boyd's State Registration for Nurses 

State Registration for Nurses. By Louie Croft Boyd, 
R. N., Graduate Colorado Training School for Nurses. 
Octovo of 149 pages. Cloth, $1.25 net. New (2d) Edition. 

Morrow's Immediate Care of Injured 

Immediate Care of the Injured. By Albert S. Mor- 
row, M. D., New York City Home for Aged and In- 
firm. Octavo of 354 pages, with 242 illustrations. 
Cloth, $2.50 net. New (2d) Edition. 

deNancrede's Anatomy NEW <7t h) edition 

Essentials of Anatomy. By Chart.es B. G. deNan- 
crede, M. D., University of Michigan. 12mo of 400 
pages, 180 illustrations. Cloth, $1.00 net. 

Morris' Materia Medica new (?«« edition 

Essentials of Materia Medica, Therapeutics, and Pre- 
scription Writing. By Henry Morris, M. D. Re- 
vised by W. A. Bastkdo, M. D., Columbia University, 
New York. 12mo of 300 pages, illustrated. 

Cloth, $1.00 net. 

Register's Fever Nursing 

A Text Book on Practical Fever Nursing. By Edward 
C. Register, M. D., North Carolina Medical College. 
Octavo of 350 pages, illustrated. Cloth, $2.50 net. 



